Closing the loop

"Mary, I just obtained the vital signs for Patient X in room 4 and here they are. His Blood Pressure was elevated at 194/92."

"umm, yeah, ok, Alice can you just re-check those it an hour?"

Mary to Charge Nurse: "So Alice never reported a patient's elevated blood pressure earlier. I'm sure what her deal is"

Alice overhearing the conversation thinks - "Oh my gosh, I told her right after I got them and she said ok and to re-check"

Does this type of scenario sound familiar to anyone? 

Unfortunately it happens all the time in nursing because very rarely we never close the loop of the conversation. 

So what does Closing the loop actually mean?


For starters it is a method to ensure all parties of a conversation understand what is being said. Sounds pretty simple, yet communication breakdown accounts for patient errors that can lead to bad outcomes including death.

Let that statements sink in a little bit. Imagine having someone you love very much die because the nurse and physician never closed the communication loop? Believe me, it happens. I have witnessed this phenomena in my career.


Closing the loop never happened!

"Nurse give 0.01 mg per kg of epi IM now"

Nurse: "Yes I will right away."

Nurse walks away gets side tracked on way to medication room. Thinks "Oh man it's been a while since I drew up epi. Did he say 1 mg per kg? I think so, so that means the kid weighs 18 pounds, so thats 8.18 kg time 1mg, so that's 8.1 mg of epi IM."

Within minutes of delivery the telemetry monitor goes wild and the child is now in cardiac arrest. Read a true case report of Epinephrine overdose here if this doesn't seem possible!

This is not a lecture of medication errors, read back initiatives, or critical thinking. Although all of these are super important and could prevent this, I want to go back to closing the loop here. Let me rewind and see how this could have gone differently!

"Nurse give 0.01 mg per kg of epi IM now please"

"OK, so that s 0.01 mg per kg IM.  Patient X weights 18 pounds. So 0.01 mg for 8.18 kg is 0.08 mg of epi. DOes that sound right Doctor?"

"Yes 0.08 mg IM sounds correct. Let me know once she receives it and we can re-evaluate her."

"I am going to draw up 0.08 mg of Epi now"

OK, sounds corny, but you get the idea. The dose was clearly articulated and discussed in a two way conversation. There were no guesses or unclear orders.



Closing the loop - What's Involved?

Crystal Clear Messages

If you look thru clear water there is usually no mistake at what lies on the bottom. You would certainly jump in right? If you asked someone to jump in brown water with no idea what the bottom was, what do you think they would do? (OK some of my friends would but that besides the point!))

We use this in Advanced Cardiac Life Support (ACLS). Clear messages are directed towards someone by name, along with exactly what is needed to be done. The person providing the message must be calm and articulate exactly what is need. 

"Erin, I need you to take the pads from the code master and connect them to the patient. I pad over the left chest and 1 pad towards the back."

"I am hooking the 2 pads up to the patient now doctor"


Clear Roles and Responsibilities

"Bob you perform chest compression for 3 minutes and then rotate out with Megan."

"Shirley you record and keep us posted to the time"

"Mark, you give medications as I order them."

"Is everybody clear of their role and job?"


The Cycle

Doctor initiates a message (Sender)

Nurse receives the message and paraphrases it back to the Doctor (Sender)

Sender verifies the message

closing the loop: tips!

  • The listener must pay attention and make eye contact whenever possible with the sender. 
  • Active Listening is a great skill to learn. This means really hearing what is said in a way that you could repeat it if necessary. An amazing skill for nurses to learn!
  • reply with "what I am hearing is... or It sounds like you asked me to..."
  • As the sender continues to speak, summarize the comments made


closing the loop: Mary and alice take 2!

"Mary I just obtained the vital signs for Patient X and I wanted to point out the blood pressure was high at 194/92."

"um ok. Grab another set in an hour"

"Mary you are asking me to re-check Patient X's vital signs in one hour. Would you like me to report those back to you? Would you like to know how the patient is doing as I was just in the room?"

"Yes Alice let me know the vitals in an hour. And yes, I'm sorry I was busy, How is the patient?"

"Patient X has a bit of a headache but didn't want me to bother you witht hat."

"Thanks Alice I think I will go see him now."

This time the conversation is more cyclic with paraphrase and summary and well as Alice making suggestions. The message is received and the loop seems to be closed until they meet again!

Take the extra time to re-state or paraphrase to the questions or statement to ensure it is clear. With all the tasks the nurse must perform, knowing the correct message first saves time and can save lives. It is well worth the extra few seconds of conversation an even the sighs and raised eyebrows you may receive. After all it is about the patient!