Research by Dagmanra Scalise
Year after year, clinicians, nurses and health care researchers say poor or ineffective communication is a major risk factor to patient safety. According to the Joint Commission on Accreditation of Healthcare Organizations, communication was the leading root cause of sentinel events in all categories in 2005.
The reasons for ineffective communication are varied: health care’s harried, stressful environment; a culture of autonomy and hierarchy that inhibits staff from speaking up if they see or suspect an error; paper processes in which illegible handwriting makes it impossible to accurately discern medication orders; a lack of team training; and daily changes in patient condition and treatment plans. There are some interactions that are particularly at risk for medical errors, such as patient handoffs or transfers and telephone orders or lab results.
In this gatefold, we present data on communication and patient safety, look at communication risk factors and examine communication strategies to improve safety. We also provide resources for further research and reading.
Effective communication depends on clarity: the speaker must convey his or her message in such a way that the listener clearly understands that message. But the truth is communication is influenced by a host of factors: gender, ethnicity, culture, professional dynamics. So a speaker’s intended message may not be what the listener hears or understands, which can compromise patient safety. The following are some key risk factors of effective communication:
A patient’s culture may influence how he or she interacts with caregivers. Language barriers can cause misunderstandings and miscommunications.
Levels of education, literacy, economics, beliefs and behaviors can differ tremendously among patients, can affect the ability of staff to communicate with one another (e.g., nurses and doctors) and can lead to miscommunication.
How well does the patient understand medical terms? Can the patient follow take-home instructions?
Gender influences relationships among staff and between caregivers and patients.
Individuals’ personalities color their daily communication and influence how others perceive them.
Urgency affects a speaker’s tone. For example, a hurried doctor or a stressed-out nurse may be perceived as curt by the patient or other staff.
Sources: Michael S. Woods, M.D., “How Communication Complicates the Patient Safety Movement,” Patient Safety & Quality Healthcare, May/June 2006; H&HN research, 2006
Ineffective communication arises from many sources, including an organization’s culture, the local environment and issues related
to the specific communication exchange. In addition, nurses and physicians communicate differently. Nurses tend to “paint a big picture” by being descriptive and narrative; while physicians want “headlines only” because they are trained to be problem-solvers. Listed are some of the sources of communication failure:
Issues
Sources: Kathleen M. Haig, Eighth Annual NPSF Congress presentation, 2006; H&HN research, 2006
When patients can’t read or don’t speak English well, the potential for error increases significantly. In the 1990s, evidence emerged that low literacy among patients was associated with adverse health outcomes. Studies showed that even patients who read at the college level preferred medical information at the seventh-grade level. And according to a 1993 study by the National Center for Education Statistics, the health of up to 90 million people may be at risk because they can’t understand or act upon health information.
For patients who don’t speak English at all, the potential for error is even more significant. A 2005 study in Pediatrics found that Spanish-speaking patients at a pediatric hospital in the Pacific Northwest who needed interpreters had twice the risk of serious medical events as those who didn’t need interpreters.
Sources: Agency for Healthcare Research and Quality, Literary and Health Outcomes, 2004; USA Today, Feb. 20, 2006; H&HN research, 2006
Improved communication is one of the Joint Commission’s 2006 National Patient Safety Goals. JCAHO requires organizations to establish processes that will help eliminate communication errors, such as:
Source: Joint Commission on Accreditation of Healthcare Organizations, 2006; H&HN research, 2006
A 2005 Australian literature review of 27 studies on clinical handoffs and patient safety from several countries, including the United States, the United Kingdom, Australia and Germany, found that system factors, organizational culture factors and individual factors impact the effectiveness of clinical handoffs. The review found that:
Sources: Australian Council for Safety and Quality in Health Care, March 2005; H&HN research, 2006
Between March 2004 and July 2005, William Beaumont Hospital, Royal Oak, Mich., prompted by a high number of variance reports (also known as incident reports), implemented a reengineering process to address patient handoffs. “The patient’s status was not being fully communicated between caregivers, so we asked ourselves, ‘How could we improve upon this?’ ” says Rita Stockman, R.N., director of hospital quality at William Beaumont Hospital.
The goals of the project included establishing performance standards for patient handoffs, identifying the data elements needed to provide high quality care to patients moving from one setting to another, and establishing the expectations of the sending and receiving teams for transfer of information and care. The hospital developed a “Transport Procedure Checklist” to document the transfer of the patient from one department and one caregiver to another. A year later, patient transfers flow more smoothly, the hospital has fewer incident reports and has improved patient safety, Stockton says.
One interesting outcome of the project: the transportation staff became much more active participants in the transfer process. “Transporters became more critical, their role became more elevated, if you will,” Stockton says.
The reengineering project involved approximately 60 people, divided into four teams and one subgroup:
Sources: H&HN interviews and research, 2006; Healthcare Benchmarks and Quality Improvement, December 2005
SBAR is a technique that provides a framework for communication between members of the health care team about a patient’s condition. It is an easy-to-remember mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how, which is essential for developing teamwork and fostering a culture of patient safety.
SBAR stands for:
Situation: What is going on with the patient?
Background: What is the clinical background?
Assessment: What is the current situation?
Recommendation: What should be done?
OSF St. Joseph Medical Center, a 157-bed hospital in Bloomington, Ill., developed two-sided SBAR pocket cards to remind clinical staff (including nurses, physicians, respiratory therapists and pharmacists) to take a standardized approach to patient communications.
Sources: Kathleen M. Haig, Eighth Annual NPSF Congress presentation; Institute for Healthcare Improvement, 2006; H&HN research, 2006
Nurses believe that poor communication is the most significant factor in preventable errors, according to a survey in the May issue of Nursing2006. The poll of nearly 5,000 nurses found that communication failures were more significant than either human errors or system failures in causing errors. In addition, just over half (54 percent) of the nurses surveyed believe that multidisciplinary team members communicate well in their work area. However, responses to the survey question were significantly higher among nurses who worked in facilities that have multidisciplinary rounds, indicating that these rounds improve team communication.
Patient Safety Survey Report
(mean score on a scale of 1 (strongly disagree) to 5 (strongly agree) across 4,826 nurses/respondents)
| I believe most errors are related to human errors | 3.7 |
| I believe most errors are related to system failures | 3.6 |
| I believe most errors are related to communication failures | 4.1 |
| Multidisciplinary team members in my work area communicate well | 3.5 |
| I am well-informed about patient-safety issues affecting my practice | 4.3 |
| Sharing experiences regarding safety issues with colleagues helps prevent errors. | 4.6 |
Source: Nursing2006, May 2006; H&HN research, 2005
The Joint Commission has a list of abbreviations that should not be used on orders or on any medication-related documentation that is handwritten or on preprinted forms. The list below provides the following substitutions:
| Do Not Use | Use Instead |
| U | Unit |
| IU | International Unit |
| Q.D, QD, q.d., qd | daily |
| Q.O.D., QOD, q.o.d., qod | every other day |
| Trailing zero (X.0 mg)* | X mg |
| Lack of leading zero (.X mg) | 0.X mg |
| MS | morphine sulfate |
| MSO and MgSO | magnesium sulfate |
*Exception: Use a trailing zero where required to demonstrate the level of precision of the value being reported, such as for laboratory results. It may not be used in medication orders or other medication-related documentation.
Source: Joint Commission on Accreditation of Healthcare Organizations, 2006; H&HN research, 2006
Communication failures have been identified as the root cause of the majority of both medical malpractice claims and major patient safety violations, including errors resulting in patient death.
Risk managers in the United States, Canada, the United Kingdom and Europe agree that up to 80 percent of malpractice claims are attributed to failures in communication and/or a lack of interpersonal skills, usually of the physician. The Joint Commission on Accreditation of Healthcare Organizations has noted that “physicians are most often sued, not for bad care, but inept communication.”
A 2003 study by JCAHO documented that communication breakdown was the root cause of more than 60 percent of 2,034 medical errors, of which 75 percent resulted in a patient’s death. In other words, 915 people died as a result of a communication error. In 2005, communication continued to lead as the root cause of sentinel events in all categories.
1. Communication
2. Patient Assessment
3. Procedural Compliance
4. Environmental Safety/Security
5. Leadership
Sources: Michael S. Woods, M.D., “How Communication Complicates the Patient Safety Movement,” Patient Safety & Quality Healthcare, May/June 2006; Joint Commission on Accreditation of Healthcare Organizations, 2006; H&HN research, 2006
This gatefold was produced by researching conference materials, published research and articles,
and conducting interviews with hospital executives.
Research: Dagmara Scalise (dscalise@healthforum.com)
Design: Chuck Lazar (clazar@healthforum.com)
This article first appeared in the August 2006 issue of H&HN magazine.
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