The dangers of not properly defining everybody's role

On 9 January, a 75-year-old woman called Catherine was brought into the emergency department (ED) with hyperkalemia. She was assessed by an emergency physician, and a decision was made to give her haemodialysis and transfer her to the intensive care unit (ICU). Unfortunately, no ICU beds were available, meaning that Catherine had to wait in the ED until a bed became available. She was admitted to the ICU eight hours after arriving at the hospital. However, as a result of a communication problem between some members of staff, haemodialysis did not start immediately and Catherine ended up having a cardiac arrest. In a nutshell, somebody having an overview of the situation, clearly defining and communicating responsibilities for each member of the team, and standardising the workflow based on high-reliability principles might have avoided this adverse event.

Date de parution : 06/2020

Thème : Communication entre les professionnels

Mots clés : Retard de prise en charge, Surcharge des SU, Organisations à haute fiabilité (HRO)

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