It was 4:56 p.m. on the surgical floor of Collins Memorial Hospital. Nurse Rhonda Fleming, an efficient head nurse with 15 years of experience, was in charge of the floor that afternoon. As in the case in many hospitals, she had responsibility for several patients herself as well as assuming supervisory responsibilities over other floor nurses. Making a final room check of her own patients prior to the arrival of her 5:00 p.m. relief, in Room 406 she found Mr. Henry Youstra, who had undergone surgery the week before and not done well, had finally died. She pulled the sheet over the face of the body and made a mental note to tell her relief to empty the room for a new patient, bed space being especially important at this time in the hospital.

After finishing her check she returned to the floor desk. The evening shift supervisor, Anne Simmons, had already arrived, and was waiting at the desk.

“Hi Ann, 406 just died, so the room’s all set to go again. Too bad. We can certainly use the space, though.”

“That’s for sure. Has 411 had her shot yet? Dr. Alpers really climbed on me yesterday about it. You know how he is.”

“No, not yet. You’d better do that right away.”

“Does the office know that 406 is ready?”

“No, you’ll need to call them after you get things taken care of.”

Nurse Supervisor Fleming then left. And Simmons gave 411 her shot and went about other duties, dropping in on her own patients, and chatting with nurses on the shift.

At 5:45 p.m. she called the office and told them that room 406 was ready for occupancy, though she and not checked the room herself. She was told that a patient would be moved from recovery and would ultimately occupy 406.

Visitors hours began at 7:00 p.m. at the hospital. As she had been doing three times daily throughout the week, as the fourth floor elevator doors opened, Mrs. Henry Youstra walked out and went down the hall to visit her husband.

At 8:00 p.m., the end of the visiting hours, Nurse Supervisor Simmons checked each of her assigned patient room to see that visitors had left. In room 406 she found Mrs. Youstra dead on the floor beside the bed containing her husband’s body.

1. What barriers to communications existed in this situation?

2. How might this miscommunication have been avoided?