CASE STUDY MISCOMMUNICATION IN HEALTHCARE A 52-year-old male patient, John D., a businessman with a history of hypertension, was admitted to a busy metropolitan hospital in Kent (UK) late on a Friday evening after experiencing severe chest pain at home. During the initial assessment, the attending physician verbally instructed the nurse to administer 25 mg of a beta-blocker. However, the nurse misheard the dosage as 50 mg. The medication was administered without cross-verification, and the patient experienced severe bradycardia and hypotension, requiring emergency intervention. The error was traced to multiple communication failures. First, the physician did not write the order or confirm it in the electronic health record (EHR). Second, there was no standardised protocol for read-back communication, where the nurse could have repeated the order to confirm accuracy. Third, environmental distractions during the handoff process contributed to the misunderstanding. Lastly, the lack of clarity in verbal communication under time pressure played a significant role. This incident highlights the critical need for clear and standardised communication in 1 healthcare settings. Implementing read-back protocols, making use of EHR for all medication orders, minimising environmental distractions, and fostering a culture where staff feel empowered to seek clarification can significantly reduce such errors. This case underscores that even seemingly minor miscommunications can have life-threatening consequences, emphasising the importance of robust communication systems in patient safety. handoff process: passaggio di consegne Answer the questions. 1. W hat was the initial medical issue that led to the patient s hospital admission? 2. What medication error occurred? 3. What immediate consequences did the patient face due to the medication error? 4. What communication method was used to give the medication order? 5. What was missing in the communication process that could have prevented the error? 6. How did environmental factors contribute to the miscommunication? 2 GROUP WORK In groups, discuss the following issues. 1. Explain why verbal communication alone is insufficient in high-stakes medical settings. 2. Think of systemic changes that could prevent miscommunication errors. 3. Explain why this case study highlights the importance of communication in healthcare. Work 343