Why you must insist that your patients use checklists too, and five ways you can get them to do it
I had surgery, on a Thursday morning, to repair a deviated septum and other sinus issues. Part of the procedure is to insert plastic stents and breathing tubes in each nostril. The stents are held into place by heavy-duty sutures that pass through the cartilage in the tip of the nose. Without the sutures it is possible for the stents to migrate up into the sinuses or down into the back of the throat.
My first follow-up with my surgeon was the next Monday at noon. (Why the follow-up was on Monday and not the preceding Friday is the subject of another newsletter on the importance of “read backs.”)
While my wife was driving me to the appointment, I began to make a mental list of the things I wanted to tell my physician. The third item on that list was that the suture on the left nostril was protruding out of the nostril about a quarter of an inch. This was the second time the suture had extended outside my nostril. The day before, Sunday, as I was getting ready to head out the door for church, I noticed it was protruding a quarter of an inch and I took a pair of small scissors and clipped the end off so that it was flush with the end of my nostril. A day later, it had protruded another quarter inch. I was wondering if the knot was unraveling, so I added the suture to my list of things to discuss with my doctor. I briefly thought about writing my list down and turning it into a checklist to make sure I didn’t forget anything.
As my wife was acting as my “Sentinel” and going to be in the examination room with me, I thought about briefing her on the things on my list as a cross-check. But, I’m a pro (or so I thought). I visit ORs all the time in the course of my work with LifeWings. I work with physicians and nurses all the time. I have a great memory. I even wrote a book (Never Go To the Hospital Alone) about how to stay safe in both the doctor’s office and the hospital - so I felt like an expert. No checklist or cross-check for me; “I’m good enough that I don’t need one.”
Of course, by now you can predict what happened. We got sidetracked on the first two things on my list. The doctor saw some things with the incision he was concerned about. The conversation, and the concern went another direction. The visit was soon over and we never confirmed that the suture was holding. I had no checklist to make sure I didn’t miss a critical item, and my wife didn’t know that I was concerned about the suture so she couldn’t provide mutual support and cross-check.
Back at home about 3 PM I could feel something was different in my nose. Although I didn’t know it at the time, the suture knot did fail and the stent had moved. I didn’t know exactly what was wrong; I just knew something was different. Slowly and almost imperceptibly the stent and tube began to migrate up into my sinus cavity. Soon thereafter it found its way into the tube that runs from the back of your lower sinuses to the back of your throat.
Around 8 PM I began to have difficulty swallowing. Soon, I couldn’t swallow at all, and was in pain. Later, I could barely talk and began to sense the taste of blood in the back of my throat. Finally around 11 PM I called my physician’s service. My doctor was not on call and I got a call back from his colleague. The new doctor explained that it was possible for the stent to migrate down into the throat and restrict the air supply. So, at midnight, I was back at the ENT clinic for an emergency visit. After a long, involved, extremely painful, and potentially dangerous process the stent was retrieved and tacked back into place with new sutures. I am completely embarrassed by my rookie mistake. I knew better, much better. But I chose an “at risk” behavior with potentially serious consequences.
I hope you learn from my bone-headed error.
One of my foundational tenets is that no patient safety system is ever truly effective without the involvement of the patient and their families. It is obvious from my experience that we must encourage patients; especially toosmart-for-their-own-good patients like me, to use checklists during their care to make sure all of their concerns are addressed. Here are five steps we can take:
Remind patients, with appropriate scripting, when the appointment is made on the telephone, to make a checklist of all of their issues and to bring it with them.
When a new patient shows up at the office or clinic, have them fill out and sign a form that explains your patient checklist policy and expectations.
On the sign-in sheet that every doctor’s office has, add a block that asks if they have prepared their checklist of questions/issues for the physician. Every single one of these sign-in sheets I have ever seen asks the patients to respond if their insurance has changed since the last visit. Why can’t we ask them if they have their checklist ready?
Physicians, as they are wrapping up the visit can use scripting like this, “Have we covered everything on your checklist?”
When office staff make their phone call to the patient to confirm the next visit, they can, with appropriate scripting, remind the patient to bring their checklist of questions/issues.
After my experience this is an issue close to my heart. To quote from my book on patient safety, “No patient will ever be truly safe unless they take an active part in their own care.” If only I had taken my own advice.