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

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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 fact have Advil Cold and Sinus; in fact, that was what she had given her older sister earlier when her mother told her to give her two Advils. The mother realized that her 12-year-old had ended up getting 120 mg of pseudoephedrine within one hour. Fortunately, her daughter was fine—before she called me, she had already called her doctor as well as poison control—but it did cause a scare for her family.

What went wrong?

  1. No adult was in the loop; at no point did the babysitter and mother speak about the plan for the child.
  2. The use of a brand name to refer to a drug instead of its generic name: the family had a bottle of generic ibuprofen in the house, but the mother used the word Advil.
  3. The person taking the medication was handed two pills without seeing the package that they came from.

It so happens that when I got the call I was reading a great book by Malcolm Gladwell called Outliers. According to the author, “A lot of the book is an attempt to describe the lives of successful people, but to tell their stories in a different way than we’re used to.”

While that’s the reason I opened the book in the first place, the part I found most striking was a chapter on plane crashes. Since strategies used to increase safety in commercial aviation have recently been applied to health care (with, admittedly, mixed reviews), it really got my attention when Gladwell wrote that communication breakdown in the cockpit had been responsible for several of the crashes that had occurred over the last 30 years. The most common of these communication breakdowns was the difficulty of junior crew members in pointing out mistakes to their captain—a difficulty obviously paralleled in health care. 

Things are starting to change, but we have a ways to go. Consider the case of the Nevada nurses who potentially infected 50,000 patients with hepatitis B, hepatitis C, and HIV: because they were afraid of repercussions, they followed unsafe practices dictated to them by the management of the facility where they worked. At the same time, how can nurses feel safe to speak up when you have a case like the Texas nurses who are facing a criminal trial for reporting a physician’s unsafe practices. With all of the advances in technology we’ve had, there are now more ways to communicate than ever—but we still need to work on the quality of that communication.

As I see it there are two things that need to happen. People need to learn how to communicate better and they need to feel safe in getting their message out. Please write us about any experiences you may have had where bad communication led to problems, or tell us if your facility has come up with any solutions—so we can all learn from each other.

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2016-11-21T13:20:07+00:00 January 19th, 2010|nursing perspective|3 Comments
Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Mary January 27, 2010 at 9:10 pm

    I like the analogy of flight attendants and nurses, pilots and doctors. I agree that nurses many times take more blame for any errors. I believe it is because we truly care what happens to our patients. I am not saying that physicians don’t care but perhaps they are not as aware of the breakdown in communications that must occur prior to an error.

  2. Peggy McDaniel January 20, 2010 at 1:19 pm

    I recently read a letter to the editor in a nursing journal that discussed the “flyover” of Minneapolis- a recent aviation error. The writer compared the pilots with doctors and the flight attendants with nurses. The point was that no where did you hear negative comments about the flight attendants. They were taking care of the passengers (doing their job) the fault was with the pilots and their inattention. She had felt that nurses accept more responsibility than they possibly should when errors occur. Lots of excellent comparisons can and should be made around reducing medical errors with aviation methods. I always thought this statistic should be publicized to get people’s attention and force improvement: Considering older stats show that approximately 90,000 people a year die from medical errors, it would take 1 jet crash a week with no survivors to equal the death toll. I for one wouldn’t get on a plane if that were happening, would you?

  3. jm January 20, 2010 at 11:20 am

    Editor’s Note: Speaking of medication errors, we’ve just heard that several school staffers in Wellesley, MA, were given insulin instead of the H1N1 vaccine. Luckily no one seems to have suffered a severe drop in blood glucose level as a result.

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