One in Seven Pages is Sent to the Wrong Physician

It's well known that many physicians are "on call" after hours and on weekends and holidays. "Call schedules" are commonplace in healthcare facilities and answering services. In an interesting study conducted at two Canadian hospitals over a two month period of time, Dr. Brian Wong found that 14% of all pages were sent to the wrong physician and were not sent to the person who was scheduled to take the call. The outcomes of misdirected calls included delay in the handling of emergency situations; 15% of the wrong pages were life-threatening situations that required immediate action. Another 32% of misdirected calls were categorized by Wong as situations requiring what he termed "urgent attention" and included highly abnormal laboratory results, significant drops in blood pressure, and oxygen saturation levels.

One thing not measured but nonetheless important, was whether or not the misdirected pages were actually answered by the person thought to be on call, but was not actually on call. With cell phones now commonplace (and usually left on all the time--unlike decades ago when physicians turned their beepers off when not on call), I imagine it would be likely that physicians could be answering pages intended for another physician, and hopefully addressing emergency situations even though not officially on call.

It's well recognized that communication delays and errors are a source of patient dissatisfaction and can even trigger litigation. With the amount of technology we have available today, ensuring that calls reach the intended physician seems easier than ever. It's disturbing that one in seven pages reached the wrong physician in this study, and this statistic is the reason why the study received a great deal of attention in the media. However, the public needs to remember that these findings reflect the experience of two specific hospitals over a relatively short period of time and cannot be generalized to all hospitals.

Reference

Wong BM, Quan S, Cheung M, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med 2009; 169: 1072-1073.