Doctor stands near a patient and looks at paperwork.

Lack of Communication Proves Fatal for Patient

Douglas Milford, 53, was found to have an enlarged thyroid, among other co-morbidities, that was causing compressive symptoms for which he was referred to Dr. Christiann Johns, a general surgeon.

In September 2019, Dr. Johns evaluated Douglas and recommended a total thyroidectomy. He was cleared for surgery in late November and presented to Dr. Johns for a pre-operative visit. Dr. Johns discussed the risks and benefits with Douglas and agreed to move forward with the surgery.

Following Douglas’s thyroidectomy, Dr. Johns didn’t note any complications or excessive bleeding but had noted a small hematoma adjacent to the incision site. Dr. Johns, therefore, elected to admit Douglas to the hospital for observation. His PACU course was otherwise uneventful.

Upon admission to the hospital, Nurse Debbie Groff cared for Douglas. Her notes indicated that he had an expected course of progress through most of the evening, reporting a pain level post-op of 5 out of 10 with stable vital signs. 

At 4:45 a.m. the following morning, Douglas began having difficulties. Nurse Groff placed a call to Dr. Johns to advise her of neck swelling and firmness and reported that Douglas felt like he was having difficulty breathing. When he continued to complain of breathing issues, Nurse Groff called a Code “CAT” around 4:50 a.m. (A Code CAT, at this facility, prompted designated health care workers to assist a patient in clinical distress).

On the way to the hospital, Dr. Johns placed a call to the hospital and was told that the Code CAT team had just left Douglas’s bedside because his neck had improved and he was not found to be in clinical distress. Dr. Johns arrived at the hospital around 5:20 a.m. At that time, Dr. Johns noted that Douglas admitted to a recent coughing spell but his vital signs were all within normal limits.

While evaluating Douglas, Dr. Johns again noted a small, non-pulsatile, non-expanding hematoma adjacent to the surgical incision site. She thoroughly assessed Douglas’s respiratory status and documented that he didn’t have an airway problem, noted nothing alarming and ordered that he remain upright with ice on his neck and be administered Ativan. 

Douglas did well over the next several hours. He ate breakfast without issue and his pain levels and vital signs remained normal. Nurses continued to assess his neck and noted at 9:01 a.m. that there had been no increase in swelling.

At 10:35 a.m., Dr. Johns returned to Douglas’s bedside and noted that his neck was soft and improving and that he had no signs of bleeding. Dr. Johns elected to keep him in the hospital for continued observation.

At 10:45 a.m., the nursing staff documented that Douglas denied any pain or difficulty swallowing or breathing. He continued to do well throughout the day with no other complications or apparent clinical changes. He had family visiting, ate meals, his pain levels remained low and his vital signs remained stable.

There were no specific assessments of his neck or his hematoma documented in the chart the remainder of the day. Dr. Johns didn’t ask for an increase in vital sign monitoring and didn’t provide instructions to the nursing staff regarding specific clinical parameters that may have prompted a call to her.

Nurse Groff was Douglas’ nurse again that evening. She took his vital signs, assessed the surgical wound and reported both as normal. Again, specific documentation of his neck was absent. At 7:45 p.m., Nurse Groff documented that Douglas had multiple family members visiting, and that he appeared anxious, requested pain medication and swallowed it without difficulty. Nurse Groff did not contact Dr. Johns to notify her of Douglas’s anxiousness or request for pain medication.

At 9 p.m., Nurse Groff noted that Douglas’s pain was a little better but that he stated that his neck felt tight. She took Douglas’s vital signs at 11:37 p.m., which were normal except for a slightly elevated pulse. Dr. Johns was not informed of Douglas’s complaints of neck tightness or elevated pulse.

At 11:45 p.m. Douglas’s blood pressure and pulse rate had risen. At 11:47 p.m., Douglas complained of neck swelling with difficulty breathing. Nurse Groff called Dr. Johns and reached her answering service. She was told Dr. Colman Hayes, Dr. Johns’s partner, was covering for her.

Nurse Groff told Dr. Hayes that the patient's vitals were stable, not mentioning the elevated blood pressure or pulse. Nurse Groff advised Dr. Hayes that she was the nurse on shift the prior evening and told him about the events of the morning and about calling a Code CAT. She said that she had been closely monitoring the patient again this shift and had not identified any clinical changes in his condition. While it is not documented that they discussed Douglas having a post-operative hematoma, both Nurse Groff and Dr. Hayes testified that they discussed the fact that Dr. Johns had identified a small hematoma and had elected to admit Douglas to the hospital.

Dr. Hayes felt comfortable that Nurse Groff was closely monitoring Douglas and was reassured knowing that he had a similar episode earlier in the day that resolved with Ativan. He ordered additional Ativan and asked Nurse Groff to call him for any changes or concerns with the patient's condition.

Douglas continued to complain of shortness of breath. At 12:40 a.m., Nurse Groff called respiratory therapy to come to the patient's room to assess his shortness of breath. A respiratory therapist (RT) documented bilateral coarse breath sounds. Nurse Groff then called Dr. Hayes again.

At 12:47 a.m., while Nurse Groff was on the phone with Dr. Hayes, one of Douglas’s family members yelled to the nurse that Douglas was gagging and spitting. The RT documented that he had started coughing up thick white secretions. Dr. Hayes told Nurse Groff that he was on his way to the hospital and to order a pulmonary consult to evaluate Douglas’ airway and get him intubated right away.

Nurse Groff returned to the room, found Douglas slumped over and not breathing and called a Code Blue. An emergency physician responded to the code and documented that upon her arrival Douglas’s neck was “quite swollen.”

Dr. Hayes took Douglas back to surgery, evacuated a 400cc hematoma and identified an arterial bleed deep within the tissues of the neck. He did not regain consciousness following surgery and passed away.

What Can We Learn?

Teamwork and good communication are essential to providing consistent, high-quality care.  Communication breakdowns between clinicians contribute to medical errors and patient harm. Communication of clinical changes is critical. Lack of communication of clinical changes can negatively impact patient safety, patient care and patient outcomes. Clinicians must convey adequate information to the provider to ensure the provider has a complete historical summary of the patient’s care and progress.

A provider’s expectations for patient monitoring and clinical status changes must be clear and concise. Detailing specific information regarding clinical changes that should be brought to your attention is necessary.

To improve the effectiveness of your communication, develop processes addressing: 

  • Standardization and protocols
    • Consider the use of checklists, team training, etc.
  • Use of SBAR technique
    • SBAR—Situation, Background, Assessment, Recommendation. This approach is a more structured form of communication and helps to ensure information is communicated in a clear and concise manner.
  • Provide clear and specific nursing instructions.
    • Define clear parameters that can prompt an escalation in care and a call to the provider
  • Promptly inform physicians of material changes in the patient’s condition
    • When nurses do not communicate changes in a patient’s condition, it can result in a delay of care, which can be life-threatening.
    • Changes in a patient’s condition can include a rise or drop in blood pressure or a change in heart rate.
  • Ensure good handoffs and communicate with your on-call physician regarding any in-patients or patients for which you may be concerned.
    • High risk, new admissions, recent post-op cases should be discussed verbally with the on-call physician.

This website uses first party and third party cookies to improve your experience and anonymously track site visits. By visiting this website, you opt-in to the use of cookies. OK