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Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician


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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