Miscommunication is a form of waste, since it can drag out a process or lead to improper outcomes.
A review at two Canadian teaching hospitals reveals that in a two-month period, 14% of all pages were sent to the wrong physician—meaning to a resident who was scheduled to be off-duty or out of the hospital—and 47% of those were urgent messages. Extrapolating, that’s about 2,000 misdirected pages per year per hospital that require an immediate response, but don’t get one, the study found.
In one example cited in the study, an incorrect pager number was posted on a whiteboard.
The study did not look at how patients were ultimately affected by the delays caused by the paging mistakes. I hope someone does investigate that part of it.
From a lean standpoint, how can this problem be addressed? While I don’t usually push technology as a solution, that may help. There may be some kind of IT system that sends pages at the push of a button, with the numbers already programmed in.
But this probably is not just about incorrect numbers. There may also have been misinformation about which doctor was on duty.
Is it a question of standard work? Probably. Of eliminating handoffs? Perhaps. What are your suggestions?