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Communications Vital to Avoid Spinal Injury, Wrong Donor Sperm

March 17, 2008
Written by: , Filed in: Practice Management
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The two separate ‘never events’ of (1) serious patient disability due to
spinal manipulative therapy, and (2) artificial insemination with the wrong
donor sperm or egg, can be prevented with good patient communications.

The National Quality Forum has listed serious patient disability due to spinal
manipulative therapy as 1 of the 28 serious but preventable health care-
related errors defined as a ‘never event.’ This is a rare situation, and very
few clinicians actually practice this type of procedure. Therefore, the error
of patient disability due to spinal manipulative therapy is restricted to a
small number of clinicians and to a small patient population.

Nonetheless, because the resulting disability is the focus of this ‘never
event,’ the level of care provided to the patient is very important. If you
are performing spinal alignments and/or if you are working as a chiropractor,
then you must immediately move patients up to the next level of care if they
experience tingles and nerve issues.

In these situations, communications between physician and patient are very
important. For example, patients may be getting care from a chiropractor, but
their physicians do not know about this situation. The danger is that the
patient may not report receiving these “outside” spinal manipulations and
something unexpected may happen to the patient while under the physician’s
care.

The physician is totally in the dark as to what is going on because of lack of
communication with the patient or chiropractor. As the clinician, you must
listen carefully to the patient and find out as much information as you can
about procedures/care being performed outside your practice.

Another ‘never event’ related to care management is artificial insemination
with the wrong donor sperm or wrong egg. This is a devastating situation when
it happens. It can be prevented with communication, making sure you get your
patient involved.
Before the procedure, communications with the patient should include
statements such as, “Okay, here are all the things that we’re working with
today. Here’s what the labels say. Is this the correct donor? Who are you and
what is this your date of birth?”

Getting the patient involved decreases the risk of using the wrong products
when trying to help get her pregnant. In this highly emotional situation, to
use the wrong donor sperm or egg is not impossible, but it is easily
prevented.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Two ‘Never Events’
Disability Due to Spinal Manipulative Therapy and Artificial Insemination With
the Wrong Donor Sperm or Egg

The two separate 'never events' of (1) serious patient disability due to spinal manipulative therapy, and (2) artificial insemination with the wrong donor sperm or egg, can be prevented with good patient communications. The National Quality Forum has listed serious patient disability due to spinal manipulative therapy as 1 of the 28 serious but preventable health care- related errors defined as a 'never event.' This is a rare situation, and very few clinicians actually practice this type of procedure. Therefore, the error of patient disability due to spinal manipulative therapy is restricted to a small number of clinicians and to a small patient population. Nonetheless, because the resulting disability is the focus of this 'never event,' the level of care provided to the patient is very important. If you are performing spinal alignments and/or if you are working as a chiropractor, then you must immediately move patients up to the next level of care if they experience tingles and nerve issues. In these situations, communications between physician and patient are very important. For example, patients may be getting care from a chiropractor, but their physicians do not know about this situation. The danger is that the patient may not report receiving these "outside" spinal manipulations and something unexpected may happen to the patient while under the physician's care. The physician is totally in the dark as to what is going on because of lack of communication with the patient or chiropractor. As the clinician, you must listen carefully to the patient and find out as much information as you can about procedures/care being performed outside your practice. Another 'never event' related to care management is artificial insemination with the wrong donor sperm or wrong egg. This is a devastating situation when it happens. It can be prevented with communication, making sure you get your patient involved. Before the procedure, communications with the patient should include statements such as, "Okay, here are all the things that we're working with today. Here's what the labels say. Is this the correct donor? Who are you and what is this your date of birth?" Getting the patient involved decreases the risk of using the wrong products when trying to help get her pregnant. In this highly emotional situation, to use the wrong donor sperm or egg is not impossible, but it is easily prevented. Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Two 'Never Events' Disability Due to Spinal Manipulative Therapy and Artificial Insemination With the Wrong Donor Sperm or Egg [text_ad]
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