In Medicine as in Aviation, Communication Breakdown Leads to Fatal Errors

By Christine Moffa, MS, RN, AJN clinical editor

Lately I’ve had communication on my brain. I’m always amazed that we get anything done in this world at the rate that messages can get lost in translation. For instance, I recently had a phone call from a mother of two girls who was upset about a medication error involving her 12-year-old daughter. While the mother was at work, the child came home from school with cold symptoms and a temperature of 102.5. The daughter called her mother and was told to take two tablets of Sudafed, which she did. About an hour later, the babysitter picked up the younger child, age nine, from school. Concerned that her sister was sleeping unusually soundly, the nine-year-old called her mother at work. Realizing that just giving her older daughter Sudafed hadn’t addressed her fever, she told her younger daughter to wake up her sister and have her take “two Advils.” 

A few hours later the mother came home from work. As she was about to give her daughter another dose of medication before bedtime, she remarked to the children that she wished she had a combination drug containing both Sudafed and Advil so that the girl wouldn’t have to swallow four separate pills. The nin- year-old informed her that they did in […]