Communication-Related Error: Strategies to Minimize the Risk

Effective communication between providers is essential in the delivery of safe, quality patient care.  When important clinical information is not communicated or is miscommunicated, errors can occur and patients can suffer harm. Consider the following cases that illustrate this risk:
 

Case 1: During a prenatal visit, a patient signed a consent for tubal ligation to be performed during a scheduled cesarean section. The medical office failed to forward the signed consent form to the hospital. In the following month, the patient was admitted to the hospital with premature rupture of membranes. The baby was delivered by emergency cesarean section, but the tubal ligation was not performed. Several weeks later, the patient had to undergo a subsequent tubal ligation procedure. 
 
Case 2: A patient with developmental disabilities presented to the emergency department for suspected urinary tract infection. The history, taken by the admitting clinician, mentioned the patient’s poorly controlled diabetes. While entering orders, the clinician was interrupted by a call from an incoming ambulance crew. After resuming his patient evaluation, the clinician forgot to enter an order for a blood glucose level. Several hours later, the patient was found unresponsive due to ketoacidosis. 

Each of these situations involved miscommunication that resulted in an adverse event. They illustrate the dual threat of poor communication as both a critical patient safety issue and a major factor in professional liability claims.

Coverys routinely analyzes closed claims data to better understand the factors contributing to malpractice claims. This data provides valuable “signals” that can lend insight into existing vulnerabilities and allow organizations to implement proactive risk and quality improvement strategies. Coverys' analysis of 6,345 events that closed between 2018 and 2022 identified 840 events involving a communication issue. Here is what the data revealed:



As staffing shortages loom and healthcare delivery becomes more fragmented, communication may continue to suffer. Rushed handoffs, complex patient care instructions and information, and frequent interruptions can be factors in ineffective communication and adverse events. Consider the following when examining communication patterns and barriers at your organization: 

Enhance communication at points of care transitions. Care transitions often involve situations in which multiple providers are required to collaborate, coordinate, and communicate effectively. Miscommunication is most likely to impact patient safety during points of care transitions. Examine and refine communication processes during these crucial periods: 

• Handoff between clinicians. Implement a structured handoff process that incorporates a standardized template to ensure that critical findings are conveyed during handoffs. Ideally, conduct the handoff process in person and include a method to check understanding of the information delivered, e.g., teach-back. Provide documentation guidelines and a compliance auditing process in your written handoff policies and procedures.
• Patient transfers. When patients are transferred between facilities or units, vital information can get lost in the shuffle. Ensure that the communication provided to the accepting facility includes a summary of treatment, services, medications, referrals, and specific instructions for follow-up care. Provide written instructions to support any verbal instructions or information that is given to the facility or patient. Utilizing structured communication techniques can ensure that essential information is conveyed. Thoroughly document the transfer process and all communications. 
• Discharge to home. To ensure a safe transition to the home setting, patients and their caregivers must understand the discharge plan and instructions. Unfortunately, the discharge process can be confusing and create misunderstanding. What’s more, the patient’s ability to understand complex verbal instructions may be compromised by physical, emotional, or cognitive barriers. Consequently, at discharge:
  • Support verbal instructions with plain language written instructions and ensure that the patient/caregiver can read and understand those instructions.
  • Encourage questions and incorporate teach-back strategies into the discharge process. A follow-up conversation with the patient after discharge can ensure that the plan of care is proceeding as intended.
  • Explore innovative models for enhancing communication with patients, such as the BATHE protocol, BOOST model, Care Transitions Intervention Model, and Transitional Care Model. These techniques can increase patient satisfaction and reduce readmission rates. 

Eliminate cultural barriers to effective team communication. Proximity does not guarantee communication proficiency. Ineffective communication may interfere with a clinical team’s ability to work cohesively. A team is most effective when each member is aware, equipped, and empowered to perform their duties with minimal barriers. Eliminate cultural barriers to effective team communication by:

• Fostering a just culture. A toxic culture may rattle the confidence of even the most seasoned clinician. When fear of retribution, ridicule, or retaliation is the filter by which team members make their decisions, disengagement and miscommunication is inevitable. So are adverse and/or sentinel events. Trust and empower everyone in your organization to speak up if they feel something is amiss or when patient safety is at risk.
• Intervening early. Emotional strain and/or skill gaps may be masked by silence, but nonverbal cues may alert a supervisor or colleague to a developing challenge before it becomes a barrier to effective communication. Provide training for managers and supervisors that teaches them to detect subtle cues that may indicate a need for emotional support or reeducation and to intervene before the need results in miscommunication or patient harm.
• Destigmatizing mental health issues. Team members may be reluctant to disclose their personal mental health challenges for fear of repercussion from leadership and/or stigmatization from their colleagues. However, supervisors and colleagues may misinterpret these internal challenges as aloofness, standoffishness, or disengagement. Work to destigmatize mental health issues or challenges in your organization. 

Minimize distractions and interruptions. Distractions and interruptions are ubiquitous in the healthcare setting and can impede effective communication. Sources of interruptions and distraction include noise, other people, alarms, overhead pages, emails, and texts. When examining communication patterns at your organization, consider the following:

• Designate “interruption-free” zones or hours. Designate areas or hours for uninterrupted clinician work. Provide a quiet private place for practitioners to communicate, especially when exchanging critical information between team members. Set expectations among staff prohibiting interruptions during handoffs or other important communication.
• Conduct handoff in the patient’s room. Medical personnel typically regard time spent in the patient’s room as “protected time” and are therefore more reluctant to interrupt a practitioner who is in a patient room. Consider providing handoff in the patient’s room when possible. 
• Empower practitioners to delay interruptions. Empower practitioners to ask an interrupter to return at another time without fear of repercussion for delaying the interruption. Similarly, educate and counsel staff regarding the link between interruption and miscommunication so they understand why they’re being asked to come back later. 
• Use mental visual bookmarks. Coach clinicians to reach a natural break point before they engage with an interruption. At that point, they should give themselves a mental or visual cue (e.g., a note or electronic health record flag) that will remind them to pick up where they left off. 
• Examine workflows. Poorly designed workflows may create the need for interruption and be the culprit in systemic communication issues among staff. Examine workflows and IT systems to detect issues that may impede effective communication. 

Miscommunication is a persistent problem in the healthcare industry. Poor communication can result in adverse events and is a frequent finding in medical malpractice claims. Examining patterns of communication and identifying opportunities for improvement can result in more effective communication and improve patient safety.


Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.