SOURCES OF MISINTERPRETATION

The interpretation of provider orders is a critical step in the provision of patient care and has historically been a process that is open to misinterpretation for a variety of reasons. Faulty communication in verbal exchanges between nurses and physicians results in errors ranging from 12% to 91% (Moss, 2005; Proctor et al., 2003; Sutcliffe et al., 2004). Practice breakdown occurs when the orders are missed or misinterpreted and results in instances of carrying out inappropriate orders culminating in an erroneous intervention (Benner et al., 2002). Although illegible handwriting is probably the most common source of misinterpretation, verbal orders not transcribed correctly, verbal orders not understood, incomplete or partial orders, abbreviations, transcription errors, and distractions are also sources of misinterpretation. Missed or mistaken orders are dangerous to patients since essential medications or therapies may be omitted, or wrong therapies or medications may be administered. The incredible volume of communications and frequent interruptions that are present in routine nurse work further contribute to the likelihood of misinterpretation.

Traditionally nurses have been confronted with illegible writing, incomplete orders, and missed orders in the routine transcription of written orders. Verbal orders have long been identified as a source of significant misinterpretation. Both the time lag that occurs between the verbal order and the writing of the order and the significant language dialects and cultural accents of providers have made this practice ineffective and unsafe. Nurses have also been challenged by hierarchical cultures of physician power and control. Challenging physician orders has been frequently discouraged, and if nurses have questioned orders, they have been intimidated or belittled. This dangerous form of power and verbal abuse makes nurses reluctant to further question provider orders. Sometimes nurses are frankly discouraged from calling physicians during night hours. This too is a dangerous practice for patient safety and quality of care that is increasingly being addressed by “rapid response systems” (Devita et al., 2006; Hillman et al., 2005), hospital intensivists who are available during the night hours. Some hospitals (e.g., Stanford University) have identified bullying behavior on the part of any employee as dangerous to a quality of work life and to patient safety, and have instituted required counseling sessions for any employee who is reported more than twice for disruptive or bullying behavior.

DESIGNING FOR SAFETY

The availability of computerized documentation systems and wireless communication technology requires examination of workflow and creation of processes that support appropriate provider orders based on standards of care, accurate interpretation of provider orders by caregivers, and workspace for focus and concentration on safe provision of care.

CASE EXAMPLES/ANALYSES

As discussed previously, practice breakdowns that involve the interpretation of provider orders are commonly associated with other categories of practice breakdown, such as clinical reasoning and attentiveness/surveillance, as the nurse’s lack of information or inappropriate application of processes often precedes the misinterpretation of an order. Thus it is relatively rare that an “interpretation of provider orders” would be identified as the primary cause of an error. Because of this, cases that involve nurses’ interpretation of provider orders that contribute to practice breakdown have been discussed in other chapters of this book. These cases will be revisited here to discuss specifically the activities associated with the clinical circumstances and nurse activities that pertain to the interpretation of provider orders.