Case Study On Communication Failure

The patient’s re-presentation the next day also highlights the breakdown in communication between the patients General Practitioner, the Career Medical Officer and Medical Registrar.

It is important that collaboration occurs between health professionals to ensure a seamless flow of work based on knowledge of the patient and their care (Stein-Parbury & Liaschenko 2007).

However, it must always be remembered that records and record keeping are an intrinsic part of the professional activities of a registered practitioner, not an optional extra.

The coroner report investigating Mr Gillam’s death does not specifically question the ethical decision-making of either the nursing or medical staff; however I believe that some questions should have been asked.

The SBAR technique provides a framework for communication between members of the health care team about a patient’s condition (Haig, Sutton, & Whittington, 2006).

It is a straightforward, easy-to-remember mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action.Medical and nursing staffs are both bound by professional ethics.Ethics are defined as the science of using moral criteria to guide human conduct and morals are accepted values and standards of human behaviour (Honderich 1995; Thain 2006 p 524).Peter Roy Gillam died as a result of sepsis and pulmonary thrombo-emboli complicating a ruptured cerebral artery aneurysm with subarachnoid haemorrhage.The coroner’s report outlines the background and history surrounding this gentleman’s presentation to his local General Practitioner and subsequent presentation to Modbury Hospital.In this case the communication between the Career Medical Officer and the patient’s General Practitioner was either ignored or overlooked as unimportant.It is vital that if the patient’s history did not match that of the General Practitioner that communication should have occurred to clarify these issues.Secondly the communication between the Medical Registrar and Career Medical Officer was also shown to be lacking.If communication tool such as SBAR (Situation-Background-Assessment-Recommendation) was used it may well have eliminated this problem by improving communication between clinicians.The most significant documentation practice is to actually write something. It should be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient.It should identify problems that have arisen and the action taken to rectify them, providing clear evidence of the care planned, the decisions made, the care delivered and the information shared (Nursing and Midwifery Council, 2004).


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