Source: https://www.ecri.org/components/HRC/Pages/RiskQual17.aspx
Timestamp: 2019-04-26 06:43:30+00:00

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Communication is the crux of safe healthcare. The ability to transmit information between patients and providers and among caregivers is central to the provision of safe, quality medical care. However, the increasingly complex healthcare environment can complicate the communication process and hinder the information exchanges necessary for optimum care.
Communication breakdowns in healthcare can occur in various ways. For example, communication can fail during patient handoffs (i.e., transfer of responsibility and accountability for patients between caregivers, such as during a change of shift or on patient discharge from the hospital). Communication breakdowns can also occur within the team of caregivers treating a patient in a particular setting (e.g., the OR), between a patient's attending physician and consulting physicians, or even between the physician and the patient. Communication lapses can also include the family members involved in the patient's care.
When communication fails, errors can occur, sometimes resulting in patient injury or death. Communication was cited as a root cause in 61% of sentinel events re-ported to the Joint Commission from 2011 through June 2013, surpassing other commonly identified issues such as care planning, patient assessment, and continuity of care (Joint Commission "Sentinel"). Refer to Figure. Communication Breakdowns among Top Root Causes for Sentinel Events Reported to the Joint Commission, 2011 through June 2013 to see where communication ranks as a root cause for reported sentinel events.
Communication breakdowns are also a leading cause of medical malpractice claims and lawsuits, as illustrated in Figure. Communication Breakdowns Factor into More Than 40% of Malpractice Cases. Of the 1,160 medical malpractice claims and lawsuits asserted from 2006 through 2010 against clinicians and organizations covered by medical professional liability insurer CRICO (Cambridge, Massachusetts), 42% of the cases reflected communication breakdowns (Hoffman and Raman). CRICO covers Harvard medical institutions and affiliated physicians.
Utilizing evidence-based practices such as these to improve quality and patient safety is one of the high-priority strategies recommended by the American Hospital Association in its report Hospitals and Care Systems of the Future.
This Guidance article* highlights the consequences of communication failures on patient care to underscore the need for effective communication strategies in healthcare organizations. Strategies described in this article include structured communication practices, such as handoffs; limits on verbal orders; policies for critical test results reporting; team training; limits on noise and distractions; technology solutions; patient and family engagement; and staff education and training. Given that communication is fundamental to risk management, quality, and patient safety, recommendations for improving communication are spread throughout Healthcare Risk Control (HRC). Refer to Resource List for additional information about tools to support many communication improvement initiatives, as well as guidelines and educational resources from medical and nursing associations on communication improvement strategies.
Assess staff attitudes about the quality of communication in their facilities, and identify opportunities for improvement.
Enlist the organization's senior leaders in demonstrating a commitment to a culture of safety.
Use structured communication tools (e.g., checklists, briefings, repeat-back techniques) to simplify and standardize communication practices.
Adopt handoff processes to communicate essential patient information during care transitions such as shift changes.
Limit verbal orders to avoid errors; when verbal orders are unavoidable, require specific practices to minimize mistakes.
Adopt standard practices for reporting critical test results and values.
Support team-based approaches to care to enhance communication among team members.
Minimize interruptions and distractions when information is being exchanged.
Support technologies that can transmit information across settings and between providers, but ensure they are planned and implemented carefully.
Engage patients in their care while following strategies to ensure they understand the information provided to them.
Provide education and training on effective communication for physicians and staff members involved in patient care.
* HRC gratefully acknowledges Kathleen Shostek, RN, ARM, B.B.A., FASHRM, CPHRM, senior healthcare risk management consultant, Sedgwick Claims Management Services, Inc., as a reviewer of this Guidance article.
Note: The majority of events have multiple root causes.
Communication is the exchange of information between individuals, groups, and organizations. It may entail a physician and nurse discussing a change to a patient’s medication dose, a surgical team reviewing a plan for surgery before beginning the procedure, or a hospital communicating to a rehabilitation facility about the discharge plans for a patient who requires physical therapy following a hip replacement procedure.
Communication can occur as a verbal, written, or electronic exchange; it can also be a combination of any of these approaches. Communication also entails nonverbal exchanges, such as facial expressions and body language.
Patients also equate good communication with safety. Although error is typically described as a deviation from the standard of care, patients who experience a medical error frequently describe the error as a consequence of a communication gap. In one study of 30 patients who were asked to tell their stories of medical error, the patients identified lack of communication, missed communication, or poor interpersonal styles of communication as the reasons for the errors (Kooienga and Stewart).
Note: Based on 1,163 malpractice cases closed 2006 through 2010 by medical professional liability insurer CRICO (Cambridge, Massachusetts); 532 of the closed cases were communication-related.
Communication failures can have a significant financial impact on the organization if they lead to patient care errors that not only result in additional care needs but also lead to legal action. As illustrated by the CRICO analysis of open and closed medical malpractice claims and lawsuits, communication breakdowns were responsible for almost half of the claims asserted (484 of 1,160 malpractices cases). The average payment for communication-related cases resolved with payment from 2006 through 2010 was $768,000, which, as illustrated in Closed Malpractice Cases with Payment: 23% Higher If Communication-Related, was higher than the average payment for all of the insurer’s malpractice cases that were closed with payment over the same time period. Typically, about one-third of the insurer’s cases are resolved with payment.
Sixty-nine percent of the cases alleged gaps in information provided to patients.
Forty percent of the cases were triggered by breakdowns in communication between two or more providers (some of the cases allege both provider-to-provider and provider-to-patient communication failures).
Defendants named in communication-related cases were typically the medical staff (named in 44% of the cases) or the organization (named in 30% of the cases).
To assist risk managers in highlighting for staff the importance of effective communication, HRC has prepared a one-page handout summarizing this data and other findings from the analysis; Handout: Communication-Related Medical Malpractice Cases.
Limit verbal orders, which can increase the risk of miscommunication that can contribute to a medication or other type of error (42 CFR § 482.23[c][i]). (For more information about best practices for verbal orders, refer to the discussion Verbal Orders, as well as the Guidance Article Medication Safety.
Implement policies for read-back verification of every verbal order to ensure the order is understood (CMS).
Standardize prescribing and communication practices to minimize drug errors (e.g., avoid dangerous abbreviations, use preprinted order sheets whenever possible, ensure patient-specific information is readily accessible to all individuals involved in providing pharmaceutical care) (42 CFR § 482.25; CMS).
Establish communication procedures to ensure integration of inpatient and outpatient services to provide continuity of care (42 CFR § 482.54[a]; CMS).
Establish communication procedures to ensure integration between the hospital ED and other hospital services (42 CFR § 482.55[a]; CMS).
Maintain a list of prohibited abbreviations, acronyms, symbols, and dose designations that can be misinterpreted and cause errors (refer to the Guidance Article Medical Abbreviations.
Limit the use of verbal orders and reports, and require a read-back process to verify the information.
Develop a process for handoff communication that provides for the opportunity for discussion between the giver and receiver of patient information regarding the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these (refer to Handoff Communication for more information).
Provide patients with information that is tailored to each patient’s age, language, and ability to understand (refer to the Guidance Article Culturally and Linguistically Competent Care, for more information on Joint Commission standards addressing patients’ linguistic and cultural needs).
Several of these accreditation requirements (i.e., listing prohibited abbreviations, limiting verbal orders, and incorporating handoffs) started as NPSGs, which are updated annually to address specific areas of concern in patient safety. Indeed, effective communication is a prerequisite for meeting many Joint Commission NPSGs, such as addressing reporting of critical results of tests and procedures, medication reconciliation, and prevention of wrong-site, wrong-procedure, and wrong-person surgery (Joint Commission “Hospital”).
The Joint Commission also requires that the medical staff’s credentialing criteria for licensed independent practitioners consider the individual’s communication skills. This provision is in concert with the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, which list communication skills with patients and their family members, as well as healthcare team members, as one of six general competencies required of medical staff members.
Given that best practices for communication are interspersed throughout regulations and standards affecting hospitals, risk managers must ensure that their organization’s policies and procedures addressing communication—from admission through discharge—are in compliance with federal, state, and local requirements, case law in the organization’s jurisdiction, and requirements of accrediting agencies used by the facility. Although effective communication underpins many of an organization’s policies and procedures, the following Action Plan describes some of the essential practices for good communication. In keeping with risk management documentation practices, the patient’s medical record must objectively document any information exchange among physicians and other healthcare providers, as well as the patient.
Action Recommendation: Assess staff attitudes about the quality of communication in their facilities, and identify opportunities for improvement.
Organizations should periodically elicit feedback from staff to assess the quality of communication in their facilities and to identify opportunities for improvement. Given that effective communication is a key characteristic of a culture of safety, surveys designed to evaluate an organization’s safety culture include questions about the organization’s approach to communication. By conducting the surveys at regular intervals, the organization can also monitor year-to-year changes in staff attitudes about communication and the effectiveness of any communication improvement initiatives.
Other questions address facility characteristics that can foster good communication: ability to work as teams, respectful treatment of staff, and exchange of information across hospital units.
Frequent and candid communication among caregivers and across organizational levels is a key characteristic of a culture of safety. The ability to speak up, voice concerns, and report near misses and errors in a healthcare organization without fear of reprisal has much to do with how well safety is embedded in the culture.
For more detailed information about assessing and implementing a culture of safety, see the Guidance Article Culture of Safety.
Action Recommendation: Use structured communication tools (e.g., checklists, briefings, repeat-back techniques) to simplify and standardize communication practices.
Tools that simplify and standardize communication practices, as well as serve as reminders, particularly during complex procedures, have been shown to enhance patient safety by reducing the occurrence of communication breakdowns that can lead to complications and adverse events. Structured tools can prompt staff to communicate pertinent information about the patient or to complete essential tasks that could be overlooked if staff relied only on memory. Structured tools used for patient handoffs, for example, remind staff of specific information that must be communicated: pertinent demographic information, a brief history and results of any physical examinations, active problems, medications and allergies, pending test results, ongoing or anticipated therapy, key patient values and preferences, and other critical information. Examples of handoff tools are reviewed in the discussion Handoff Communication.
Risk managers should support the use of structured communication techniques, such as checklists, briefings, debriefings, and handoffs, which are highlighted in Table. Structured Communication Tools. Examples are further described in this discussion.
In the OR environment, many surgical teams use a threepart checklist to improve team communication and reinforce OR safety practices. Called the World Health Organization (WHO) Surgical Safety Checklist, the check-list reminds the surgical team to review basic but critical steps that sometimes get overlooked at three different points: before anesthesia is started, before the surgeon begins cutting, and before the patient leaves the OR.
Implementation of the 19-item surgical safety checklist reduced complications and deaths associated with surgery, according to a study in the New England Journal of Medicine (Haynes et al.). The study, which included eight hospitals from eight global cities, found that the rates of death (1.5%) and complications (11.0%) before implementation of the checklist were greatly reduced (to 0.8% and 7.0%, respectively) among patients at least 16 years of age who were undergoing noncardiac surgery. Elements of the surgical safety checklist include verification of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery. Refer to Resource List for information on obtaining the WHO Surgical Safety Checklist online.
It is important to guard against allowing completion of a checklist to become perfunctory. All activity should cease and everyone on the team should be attentive while the elements of the safety checklist are completed. This enables anyone with questions, concerns, or information about the patient’s safety to speak up and provide input before a procedure commences. The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery combines the use of a checklist and a “time out” so that the team members can focus on actively confirming the patient identify, the site of operation, and the procedure to be done (Joint Commission “Hospital”). For more information, refer to the Guidance article Wrong-Site Surgery.
Another freely available checklist is a daily goals checklist, used during morning and evening rounds of care, to prompt the care team to review what needs to be accomplished for the day to ensure the discharge goals for the patient are safely met. The daily goals checklist is included in the Comprehensive Unit-based Safety Program (CUSP) toolkit, which was developed at the Johns Hopkins Hospital with funding from AHRQ, to promote safe patient care using teamwork and effective communication. Information about accessing the CUSP toolkit and the daily goals checklist from AHRQ’s website is available in Resource List. In addition see, the ICU Patient Safety: Daily Goals.
Briefings, debriefings, and huddles provide healthcare teams an opportunity to briefly review a care plan or an approach to a particular procedure to ensure all team members are collectively aware of pertinent information. For example, in the OR environment, the surgical safety checklist can be used along with a preoperative briefing to convey patient and procedural information and to give team members an opportunity to voice concerns and clarify misunderstandings before proceeding. In one study, presurgery briefings involving all members of the surgical team and the use of a checklist reduced incidences of communication failures and facilitated proactive team communication (Lingard et al.).
What happened overnight that the incoming provider needs to know about?
Where should the incoming provider begin rounds (e.g., Does a patient need immediate attention? Will a patient be transferred from the unit?)?
What issues affecting patient safety are anticipated (e.g., equipment availability, staffing, provider skill mix)?
Refer to Resource List for information on accessing the tool online. The briefing tool, which is included in the CUSP toolkit from AHRQ, is intended to be used with the daily goals checklist to promote teamwork and communication on care units.
What are the lessons learned and to be shared?
What glitches were identified that need to be fixed, including system, equipment, and process issues?
In addition to briefings and debriefings, healthcare organizations have adopted the idea of “safety huddles” for staff to exchange patient information, make and share plans to ensure coordinated patient care, or address a particular issue as a team. Studies have shown that huddles can improve patient safety by promoting efficient exchange of information, providing a venue to raise concerns, and enhancing working relationships (Goldenhar et al.). For example, during a 5- to 10-minute shift-change meeting, outgoing staff can report any critical patient information that the incoming staff should know, including code status, diagnosis, precautions, telemetry status, scheduled tests, falls risk, safety issues, and a general care plan for the day. Staff at one hospital also used the shift-change safety huddle as an opportunity to review educational opportunities, such as in-services, that are offered during the day (Chapman).
Repeat- and teach-back communication lets staff check whether a person, such as another staff member or a patient, understands instructions and information. For example, a unit nurse might repeat back instructions from a patient’s physician to verify understanding, clarify as needed, and review important information one more time. Given the importance of repeat-back practices to prevent misunderstandings, Joint Commission accreditation standards and CMS CoPs reinforce this practice. The Joint Commission’s accreditation standards, for example, require caregivers to repeat back any verbal order or verbal report of a critical test result to verify the information (see the discussion Verbal Orders for more information about these requirements).
Engaging patients in teach-back processes can also prevent communication breakdowns between provider and patient. For example, having patients teach back what they understand after a new medication is prescribed or after informed consent discussions has been shown to improve their overall comprehension. Patients might even be asked to demonstrate what they have learned if operation of a device, such as a glucose meter, is involved. A study to evaluate patients’ comprehension following informed consent discussions about their upcoming surgical procedure found that the mean comprehension in the group asked to teach back was significantly higher (71%) than the mean comprehension in the group that was not asked to teach back (68%) (Fink et al.). The study’s researchers note that providers spent an average of 2.6 minutes longer to obtain informed consent using the teach-back method, but most indicated that they felt the additional time was acceptable to enhance the surgical informed consent process.
Keeping in mind the hours, weeks, months, and even years that may be involved in defending litigation for lack of informed consent, risk managers should encourage providers to take a few extra minutes to ensure patient understanding. For additional information about teach-back approaches for patients, refer to the Guidance Article Health Literacy.
The Institute of Medicine noted in its report Crossing the Quality Chasm that when information necessary for the care of a patient is missed, forgotten, or lost during transitions (i.e., handoffs), safety is compromised (IOM). Patient handoffs occur multiple times each day for every patient—during shift changes, when a patient transfers to a different level of care, when a patient is sent to another department for a procedure such as diagnostic imaging or physical therapy, and when a physician transfers responsibility (referred to as a “sign out” procedure) for caring for a hospitalized patient to another physician. Consequently, thousands of patient handoffs occur daily in every hospital. One teaching hospital calculates that as many as 4,000 provider-to-provider handoffs occur daily at the hospital (Vidyarthi).
During a handoff, patient-specific information is conveyed from one caregiver to another or from one level of care to another. This information includes the patient’s current condition, recent changes in condition, ongoing treatment, pending test results, and possible changes or complications that might occur (refer to Handoff Essentials for a list of information to include in the exchange). The provider taking on responsibility for a patient’s care has a chance to ask questions to close any gaps in information about the patient. The exchange could lead to new insights about the patient’s condition as a result of both providers sharing perspectives with each other. Additionally, a handoff could even reveal a previously undetected error in the patient’s care, enabling the providers to intervene to stop the error from harming the patient.
An SBAR Poster and Pocket Cards for staff are available for reprinting.
A third handoff mnemonic, I-PASS, was developed by a children’s hospital to standardize communication during hospital shift changes (Starmer et al.). It focuses on key information: Illness severity; Patient summary; Action list for the next team; Situation awareness and contingency plans; and Synthesis and “read-back” of the information.
Refer to Resource List for information on accessing these handoff tools online. Kaiser Permanente’s SBAR toolkit is available for download from the Institute for Healthcare Improvement’s website. The I PASS the BATON handoff tool is described in the TeamSTEPPS course on teamwork and communication developed by AHRQ and DoD. I-PASS materials available online include a staff education module on communication and the I-PASS handoff tool. Additionally, the Association of periOperative Registered Nurses provides a web-based toolkit to standardize handoff communication, which includes several sample handoff tools.
In addition to the handoff tools that rely on mnemonics, organizations have developed other standardized handoff processes. The Emergency Medicine Patient Safety Foundation has developed the Safer Sign Out form and protocol to improve the safety and reliability of end-of-shift handoffs. Use of the protocol could have helped to prevent the ED event described earlier resulting in the failure to communicate critical test results. Refer to Resource List for information on accessing the form and protocol online.
Handoff processes have also been incorporated into patient transport using what are often called “ticket to ride” forms. The forms are used to communicate essential information about a patient being transported from one unit to another. Information includes whether a patient is at risk of falling, pertinent medical information (e.g., code status, oxygen needs), communication issues (e.g., hearing impairment, language needs), and isolation precautions (West).
For any handoff to be effective, it must allow for an interactive exchange between the giver and receiver of patient information in a place free of distractions and interruptions. See Strategies for Effective Handoffs for recommendations to improve handoff communication.
Verbal and telephone orders for medications and medical care are susceptible to error. Consider the environment of a busy clinical setting—caregivers coming and going, multiple conversations being held concurrently, the sounds of clinical and nonclinical equipment operating, and the noise of pages, telephones ringing, and alarms sounding. All these factors contribute to the possibility that orders or test results communicated verbally or by telephone will be heard incorrectly or misunderstood. This is particularly true with orders for medications that have sound-alike drug names.
Verbal orders should be avoided when possible, as required by Joint Commission accreditation standards and CMS CoPs. When it is highly impractical or impossible for the prescriber to write down orders or enter orders into a CPOE system at the time they are given, verbal or telephone orders may be the only available alternative. The receiver of the order is expected to write down the verbal or telephone orders as they are given and to read back the information as it is written for confirmation (Joint Commission Comprehensive).
Methods to demonstrate that the verbal order was written down and read back vary among healthcare organizations. Some opt to have the receiver of the orders document “verbal order read-back” in the patient medical record, while others use forms designed to capture the verbal order read-back process with a check-off and signature. In the case of electronic records, a keystroke or additional screen notation can be used. It is important that compliance with the read-back process be monitored through observation and/or record audits. In accordance with hospital policy and state and federal regulations, the ordering practitioner must promptly verify, sign, date, and time the order (42 CFR § 482.24[c]).
Based on reports of misheard drug names and errors involving other orders, as well as information in the literature on errors stemming from incorrect verbal and telephone orders, the Pennsylvania Patient Safety Authority, an independent state agency charged with analyzing reports of events and near misses from healthcare facilities in the state, has identified recommended practices for verbal orders. Refer to Safe Practices for Verbal Orders for the recommendations. Additionally, the Authority developed a verbal orders toolkit to assist facilities in assessing practices involving verbal orders, developing policies and procedures, and educating frontline staff on safe practices related to verbal orders. Refer to Resource List for information on accessing the toolkit online.
Patient treatment delays and failures to follow up on important abnormal diagnostic tests have occurred because of communication delays or breakdowns in the reporting of critical test results and values within the healthcare facility. Delays, failures, and inaccuracies in reporting test results place patients at risk for treatment delays, omissions, and errors. Cases involving failure in the timely reporting of critical lab results are a frequent source of lawsuits filed against hospitals, laboratories, and physicians (Dighe et al.).
To address the communication breakdowns that can occur with test results reporting, the Joint Commission established an NPSG to improve the effectiveness of communication among caregivers that requires accredited organizations to report critical results of tests and diagnostic procedures on a timely basis (Joint Commission “Hospital”).
In order to improve the timeliness of reporting, each diagnostic and clinical area in the facility, in conjunction with the physicians who provide care in each area, should first identify which tests and results are critical. One definition of “critical” that has been used is any test or test result that would immediately change the course of care. Specific tests and results are defined by each facility; designation of a test as critical usually involves some consideration of the associated clinical condition. An example of a critical test could be a computed tomography head scan to rule out subdural hematoma following head trauma. Conversely, while an electrocardiogram (ECG) in itself may not be a critical test, an ECG result that reveals a cardiac arrhythmia requiring immediate intervention would be a critical result. Some facilities allow the physician to specify that a test is critical when ordering it (Spath).
The procedures should address measures for reporting results to a backup healthcare provider if the ordering clinician is unavailable. Additionally, the procedures should incorporate read-back practices if the results are reported verbally (refer to the discussion Verbal Orders for information on read-back methods) (“Safe Patient”).
Risk managers should ensure that test turnaround times are periodically monitored and evaluated, investigate instances in which results are not properly communicated, and implement improvements when needed.
A comprehensive toolkit for communicating critical results is available online from the Massachusetts Coalition for the Prevention of Medical Errors. Refer to Resource List for more information. Additional information on test results reporting in physician practices is available in the Guidance Article Test Tracking and Follow-Up.
Traditional hospital hierarchies that place frontline caregivers at the bottom and physicians at the top can hinder communication. Effective communication is best achieved in an environment in which all providers and staff work as a team. Studies have demonstrated that a team-based approach to care delivery can enhance communication and improve patient outcomes.
A study published in 2011 reported that facilities participating in a Veterans Health Administration (VHA) medical team training program experienced a 17% decrease in surgical morbidity rates (Young-Xu et al.). The retrospective study, which included 42 VHA facilities that implemented the program and 32 facilities that did not, analyzed data from 119,383 total surgical procedures. While the risk of surgical complications declined in both groups, the decline was 50% greater in the group that received the medical team training. The researchers conclude that participation in the VHA medical team training program, which emphasizes communication and teamwork during an operation through checklist-driven briefings and debriefings, is associated with lower surgical morbidity.
Healthcare facilities are providing team-building skills to break down hierarchies and foster good communication skills. Drawing on the experience of other complex, high-risk industries, healthcare facilities have turned to the aviation industry to support team building and communication with an approach called crew resource management (CRM). In aviation, CRM is used to train flight crews in critical communication, stress management, and team building.
Conducting a presurgery briefing to introduce all team members. It has been shown that people who know each other by their first names are more likely to speak up if they see a problem.
Using the briefing to review the upcoming procedure (identification of the patient; confirmation of the procedure to be performed, as well as site, side, or level; and summation of the patient’s medical history) and to alert team members to potential problems and key portions of the procedure.
Conducting a debriefing after the procedure to review what went well and what could have been done better.
AHRQ and DoD have collaborated to develop a team training program called the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) system, an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals. Rooted in more than 20 years of research and lessons from the application of teamwork principles, the program is available online as a multimedia educational tool for healthcare providers and organizations. The TeamSTEPPS toolkit includes materials for classroom teaching, slide presentations, videos, case studies, and coaching exercises for interdisciplinary team training to help reduce the incidence of medical errors. The video vignettes depict staff interaction situations and patient care examples to help learners identify opportunities for more effective communication and enhanced teamwork to improve patient outcomes. Refer to Resource List for information on accessing the toolkit online.
While healthcare organizations can empower staff at all levels to speak up if there is any concern that an unsafe condition exists for the patient, conflicts can still arise. Because of this, it is important to provide specific guidance on the most direct means of communication in making decisions regarding patient care. Healthcare facilities should have chain-of-command policies in place giving providers and staff clear lines of authority and paths of communication to follow for situations that may place patients at risk. For more information, see the Guidance Article Chain of Command.
Behaviors that intimidate or belittle staff members and hinder open communication are counterproductive to a team environment and a culture of safety. Healthcare organizations must strive to prevent or correct intimidating or disrespectful behaviors of physicians or others because these behaviors have a negative effect on the communication and collaboration necessary for safe patient care. The use of communication tools, such as briefings, checklists, and structured handoffs, will be much less effective if staff are reluctant to speak up because they are threatened by intimidating behavior. The Joint Commission has drawn attention to the issue with a Sentinel Event Alert (Joint Commission “Behaviors”) and accreditation standards that require healthcare organizations to address disruptive behavior. For more information, see the Guidance Article Disruptive Practitioner Behavior.
Interruptions and distractions occur frequently in healthcare institutions, and the effects of interruptions can be detrimental to effective communication. During handoffs, for example, when information about a patient is transferred from one provider to another, caregivers should limit interruptions to focus on the information being exchanged.
Providing a well-lit and quiet place for a handoff exchange will help to minimize distractions and ensure an effective exchange. Borrowing from the aviation industry, some organizations have adopted the idea of a “sterile cockpit” during the transfer of patient information. Just as the cockpit crew is prohibited from performing nonessential duties and activities during key phases of flight, healthcare providers know that during the handoff, they must focus their attention on exchanging essential patient information and limit interruptions (Mistry et al.).
Even handheld devices intended to promote communication can be a source of distraction. One recent study found that healthcare providers who use smartphones during attending rounds can become seriously distracted during moments of important information transfer and thus cause risk of patient harm (Katz-Sidlow et al.). While an outright ban on smartphone use is likely impractical—and possibly even counterproductive, since these devices offer many legitimate benefits—effective policies regarding smartphone use are essential to eliminate distractions from smartphone use that can negatively affect patient care delivery. The success of such policies will depend on support from key leadership and cooperation from mobile device users, including clinical and nonclinical staff, independent physicians, patients, and visitors. For more information on developing smartphone use policies, refer to the April 2013 Risk Management Reporter article Judgment Call: Smartphone Use in Hospitals Requires Smart Policies.
When used properly, technologies that transmit information across settings and between care providers bring consistency and coordination to care practices and promote communication among providers. Electronic health records can provide caregivers with consistent, accessible patient information on such issues as whether a newly ordered medication was administered, whether lab tests were done, or whether a do-not-resuscitate order is in place. Additionally, health information technology (IT), such as CPOE systems, can reduce miscommunication involving handwritten medical orders such as medication orders, orders for laboratory tests, and treatment orders.
If not planned and implemented carefully, however, health IT can jeopardize effective communication and patient safety. For example, ECRI Institute has identified data entry errors in the wrong patient record as among the most frequent type of error associated with health IT (ECRI Institute PSO). While these errors are sometimes the result of human factors—a provider inadvertently accessing the wrong patient record—these errors can also occur when software and system flaws cause the wrong data to be associated with a patient record. Failure to properly build the interfaces between two health IT systems can prevent important information from transferring from one record to another (e.g., a critical result from a laboratory test fails to transfer from a laboratory information system to the patient’s electronic health record).
For more guidance on the risk manager’s role in ensuring the successful implementation of health IT systems, refer to the June 2013 Risk Management Reporter article Risk Managers’ 10 Strategies for Health IT Success.
Action Recommendation: Engage patients in their care while following strategies to ensure they understand the information provided to them.
An event, described in AHRQ’s online case study review, WebM&M, illustrates how poor communication between a patient and provider, compounded by language differences, can place the patient at increased risk for adverse events (Engel).
The event occurred when a woman with a torn anterior cruciate ligament (ACL) underwent surgery to repair it. During the procedure, the surgeon determined that her ACL was only partially torn, so instead of an ACL repair, the surgeon performed microfracture to address damage to the intraarticular cartilage and repaired her meniscus. After the procedure, the surgeon attempted to verbally communicate the necessary change in discharge instructions, which involved the leg being completely non-weight-bearing as opposed to 50% weight-bearing, but the woman was too groggy from anesthesia to understand. The surgeon called the number in her chart and left the revised instructions with the patient’s mother-in-law, but due to limited health literacy, she failed to understand the changes. After discharge, the patient mistakenly followed the original postprocedure instructions because they were not amended in writing, possibly harming her chances for a full recovery.
Communication breakdowns, possibly leading to patient harm, can occur if healthcare providers fail to engage their patients and to adopt measures to ensure they are understood by their patients. Refer to 10 Tips for Communicating with Patients for a list of suggestions. Additional information is available in the Guidance Articles Culturally and Linguistically Competent Care, Discharge Planning, and Health Literacy. Additional tools to promote effective communication with patients—Health Literacy: Checklist for Creating or Evaluating Materials and Health Literacy: Handout for In-Person Communication—are available as well.
Careful consideration must be given to communicating an unanticipated outcome to a patient and the patient’s family members. The topic is discussed in depth in the Guidance Article Disclosure of Unanticipated Outcomes.
Risk managers are uniquely positioned to promote communication improvement efforts in their facilities. Physicians and other staff members involved in patient care should be provided with opportunities to enhance communication skills formally through completion of education and training programs and informally through peer evaluations.
The content for an education and training program on communication is highlighted in Learning Objectives for Staff Training in Communication. Risk managers should ensure that the training program provides adult learners with opportunities for active participation through role-playing, simulation, and discussion of effective and ineffective communication techniques. Case studies, like the examples in this Guidance article, can be used to stimulate discussion about communication breakdowns. Several case studies, as well as questions to provoke discussion, are featured in Communication and Disclosure Training Program.
42 CFR § 482.23(c)(3)(i) (2012).
42 CFR § 482.24(c)(2) (2012).
42 CFR § 482.25 (2012).
42 CFR § 482.54(a) (2012).
42 CFR § 482.55(a) (2012).
Denham CR. SBAR for patients. J Patient Saf 2008 Mar;4(1): 38-48.
ECRI Institute PSO. ECRI Institute PSO Deep Dive: health information technology. Plymouth Meeting (PA): ECRI Institute PSO; 2013.
Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001.
Comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission Resources; 2013.
Vidyarthi AP. Triple handoff [online]. WebM&M 2006 Sep [cited 2013 Aug 9]. http://www.webmm.ahrq.gov/case.aspx?
Briefings and debriefings A morning briefing tool promotes effective communication between two or more people, such as a night nurse and an incoming physician, before patient rounds in an inpatient unit.
Checklists A surgical safety checklist reminds team members to address basic but critical steps at three points: before anesthesia, before the surgeon makes an incision, and before the patient leaves the OR.
Handoffs Patient-specific information is conveyed from one caregiver to another or from one level of care to another. Healthcare staff use the SBAR (i.e., situation, background, assessment, recommendation) technique to standardize what information is communicated.
Huddles A 5- to 10-minute huddle gives an opportunity for providers and staff to communicate new critical patient information or discuss and plan how to handle an emerging or changing situation on the care unit.
teach back A unit nurse repeats back instructions from a patient's physician to verify understanding, clarify as needed, and review the important information one more time; a patient demonstrates his or her understanding of how to use a device to manage his or her care.
Allow enough time for the handoff exchange.
Limit distractions and interruptions as much as possible.
Use clear language and be concise.
Limit the exchange of information to that which is necessary to provide safe patient care.
Allow for interactive communication in which the receiver of patient information has time to review it and in which the giver and receiver of patient information each have an opportunity to ask questions of the other.
Require a repeat-back process for verification of received information.
Require a transfer of responsibility for the patient, in addition to the transfer of information, as part of the handoff.
Educate staff on how to use the handoff tool.
Require that the verbal order be clearly communicated. For example, the name of a drug can be spelled out; use "d as in 'David,'" "b as in 'bravo,'" and so forth.
Provide brand and generic names of a medication, and include the purpose of the drug in the order.
Avoid confusion with spoken numbers by pronouncing digits separately (e.g., 50 mg should be enunciated as "fifty milligrams, five-zero milligrams" to avoid confusion with 15 mg).
Include the mg/kg dose along with the patient-specific dose for all verbal neonatal and pediatric medication orders.
Have a second person listen to the verbal order whenever possible.
Record the verbal order directly onto an order sheet in the patient's chart. Do not transcribe it from a scrap of paper.
Make sure that the verbal order includes the patient's name, age, and weight; the drug name; the dosage form; the exact strength or concentration; the dose, frequency, and route; the quantity and/or duration of medication; the purpose or indication; specific instructions for use; the prescriber's name and telephone number, when appropriate; and the name of the individual transmitting the order (if that individual is different from the prescriber).
Require the receiver to provide the date and time and his or her signature with the order and to document it according to procedure.
Limit the number of personnel who may receive telephone orders.
Limit verbal orders to orders for formulary drugs.
Whenever possible, have a pharmacist receive verbal orders for medications.
Ensure communication with patients is at or below a sixth-grade reading level.
Limit the complexity and quantity of information provided.
Avoid medical jargon when it is not necessary; use terms like "earache" and "heart attack" instead of "otitis media" and "myocardial infarction."
Repeat and reinforce key information to provide patients the opportunity to receive and retain their instructions.
Ask patients to repeat back instructions in their own words to verify their comprehension and clarify any misunderstandings.
Provide reading material that is printed in a font size and typeface that can be read by the patient, particularly seniors who may have difficulty reading small text.
Demonstrate cultural awareness and sensitivity to the patient's preferences.
Provide information in the patient's language.
Speak slowly and clearly with the patient, and allow time for the patient to ask questions.
Initiate follow-up contact with patients after hospital discharge to give the patient an opportunity to clarify instructions and to ensure posthospital care coordination.
Time should also be set aside for staff to demonstrate their understanding of and familiarity with the communication strategies and tools covered during the training session.

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