Ebola, Team Communication, and Shame: But Shame on Whom?

Abstract

Examined as an isolated situation, and through the lens of a rare and feared disease, Mr. Duncan's case seems ripe for second-guessing the physicians and nurses who cared for him. But viewed from the perspective of what we know about errors and team communication, his case is all too common. Nearly 440,000 patient deaths in the U.S. each year may be attributable to medical errors. Breakdowns in communication among health care teams contribute in the majority of these errors. The culture of health care does not seem to foster functional, effective communication between and among professionals. Why? And more importantly, why do we not do something about it?

Diagnostic error in the emergency department: learning from national patient safety incident report analysis

“…2, that add up to an overall system modification could help address the multiple causes of diagnostic error and improve emergency department diagnosis. “Blame and shame” approaches do not contribute to learning and system improvement [76]. Instead, future research should be directed towards implementing suggested interventions with a system-oriented direction.…”

The CARE approach to reducing diagnostic errors

“…For example, the first Ebola case in America that led to the death of Thomas Eric Duncan was no fault of any particular healthcare worker but instead a volatile combination of a rapidly progressive disease and a crucial communication breakdown. Duncan was seen by a number of physicians, nurses, and nursing assistants, and key information such as travel history, febrile status, and signs and symptoms of Ebola disease were recorded but never effectively communicated from provider to provider …”

Working Side By Side, But Not Talking Enough: Accident Causation in the Emergency Department Care of Thomas Eric Duncan

“…Continued investigation of how such skills can be better taught to students and residents, and how outcomes can be meaningfully incorporated into quality measures, will benefit health professions by ultimately keeping more of our patients safe. & (Shannon 2015). Contrary to her belief that medical errors due to communication failure are a particular problem in the United States, the problem is probably universal, albeit to varying degrees in different countries and health care settings.…”

“…In the review of delayed diagnosis of Ebola virus disease (EVD) at Texas Health Presbyterian Hospital, Shannon (2015) uses root cause analysis and reference to hierarchies in medicine to emphasize systems improvement rather than a "blame and shame" approach. We agree that unbalanced focus at the "sharp end" of the error reduces the likelihood of learning all that can be gained from this case, but disagree that hierarchy, professional segregation, and unclear role designations are core to the communication lapses that occurred.…”