Pages to Doctors Don't Always Hit the Mark

Mistakes can cause treatment delays and jeopardize care, review suggests

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By Amanda Gardner
HealthDay Reporter

FRIDAY, June 19 (HealthDay News) -- Dr. Brian Wong, a physician and lecturer at the University of Toronto, was enjoying a rare Saturday off and not on call when his pager unexpectedly beeped.

"I answered the page, and there was the nurse on the other end quite frustrated because she had been calling repeatedly to try to get in touch with another doctor whose patient was having chest pains," he recalled.

Wong was eventually able to identify the correct doctor, but the confusion had been the result of a mistake many people make (but probably hope didn't take place in the health-care world): Two numbers on the pager had been transposed.

"The doctor had actually been available all day and wasn't reached because of a simple transcription error," Wong said. "Information from the paper-based schedule onto the white board hadn't been transferred correctly."

As it turns out, this was not an isolated incident. An investigation by Wong and other physicians, described in the June 8 issue of the Archives of Internal Medicine, turned up many similar occurrences.

A review of hospital records from two busy Canadian hospitals -- Sunnybrook Health Sciences Centre and the Toronto General Hospital, both affiliated with the University of Toronto -- during a two-month period in early 2008 found that 14 percent of in-hospital pages were sent to the wrong physician when that physician was off duty and out of the hospital.

Almost half of these needed a quick response: 15 percent were marked as emergencies, warranting an immediate reply, and 32 percent were marked urgent, meaning a response was needed within an hour.

The review found that 36 percent were sent during the "post-call" period, which is the day after an on-call shift, 22 percent were sent in the evening and 21 percent during scheduled academic half-days.

"A lot of them are examples of numbers being switched or a paper schedule that hadn't been updated," Wong said.

Although these misdirected pages did result in "delays and inefficiencies," the authors reported, they said it's not known if the mistakes actually resulted in patient harm.

The findings were much the same in both hospitals, even though each has different paging systems in place, suggesting that other hospitals might be experiencing similar woes.

A previous study of 14,000 hospital admissions had found that communication problems in general trumped even medication errors as a source of preventable disability or death.

The researchers are now looking into why these mistakes occurred and have been making changes in hospital systems.

"We started to investigate how it was that nurses identified doctors to page them," Wong explained. "We realized that the process was not standardized. Some people would look in charts, some on the white board, so we centralized that information in one place -- in an online Web-based paging system."

Wong said it takes him about two hours a month to maintain the system.

Physicians are also now divided into four teams, with one person in each team being responsible for answering pages during a shift. The paging system is set up to contact that doctor at the given time.

"The nurses don't have to think of a doctor," he said. "They can go on the computer, type in "Team A" and one option shows up, whereas in the past they couldn't do that. In a way, it's making nurses think of physicians as a role instead of a person."

More information

The U.S. Agency for Healthcare Research and Quality has more on medical errors.

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