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Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician
  1. Brian M Wong1,3,6,
  2. C Mark Cheung1,2,3,
  3. Hasan Dharamshi3,
  4. Sonia Dyal3,
  5. Alex Kiss7,
  6. Dante Morra1,4,5,8,
  7. Sherman Quan4,5,
  8. Khalil Sivjee1,3,
  9. Edward E Etchells1,3,6
  1. 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
  3. 3Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  4. 4University Health Network, Toronto, Ontario, Canada
  5. 5Centre for Innovation in Complex Care, University Health Network University of Toronto, Toronto, Ontario, Canada
  6. 6Centre for Patient Safety, University of Toronto, Toronto, Ontario, Canada
  7. 7Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  8. 8Centre for Interprofessional Education, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Brian M Wong, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room H466, Toronto, Ontario M4N 3M5 Canada; brianm.wong{at}


Background One in seven pages are sent to the wrong physician and may result in unnecessary delays that potentially threaten patient safety. The authors aimed to implement a new team-based paging process to reduce pages sent to the wrong physician.

Methods The authors redesigned the paging process on general internal medicine (GIM) wards at a Canadian academic medical centre by implementing a standardised team-based paging process (pages directed to one physician responsible for receiving pages on behalf of the entire physician team) using rapid-cycle change methods. The authors evaluated the intervention using a controlled before–after study design by measuring pages sent to the wrong physician before and after implementation of the redesigned paging process.

Results Pages sent to the wrong physician from the GIM (intervention) wards decreased from 14% to 3% (11% reduction), while pages sent to the wrong physician from control wards fell from 13% to 7% (6% reduction). The difference between the intervention wards and the control wards was significant (5% greater reduction in the intervention group compared with the control group, p=0.008). Nurses were more satisfied with team-based paging than the existing paging process. Team-based paging may, however, introduce changes in communication workflow that lead to increased paging interruptions for certain members of the physician team.

Conclusions The authors successfully redesigned the hospital's paging process to decrease pages sent to the wrong physician. They recommend that the frequency of pages sent to the wrong physician is measured and changes be implemented to paging processes to reduce this error.

  • Clinical communication
  • nurse-to-physician communication
  • paging
  • quality improvement
  • academic medical centre
  • communication errors
  • patient safety
  • communication
  • medical education
  • adverse events
  • epidemiology and detection
  • cognitive biases
  • diagnostic errors
  • human factors
  • medication reconciliation
  • information technology
  • evidence-based medicine
  • healthcare quality improvement
  • continuous quality improvement
  • duty hours

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  • Funding This study was funded by the Chair of Medicine/Academic Hospitals Quality and Safety Partners Intramural Grant (Department of Medicine, University of Toronto). The funding programme had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

  • Competing interests None.

  • Ethics approval Sunnybrook Health Sciences Centre Research Ethics Office.

  • Provenance and peer review Not commissioned; externally peer reviewed.