Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.

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