2 The researchers found that communication problems were relatively straightforward and fell into four categories: (1) communications that were too late to be effective, (2) failure to communicate with all the relevant individuals on the team, (3) content that was not consistently complete and accurate, and (4) communications whose purposes were not achieved-i.e., issues were left unresolved until the point of urgency. 13, 14, 15Īnalysis of 421 communication events in the operating room found communication failures in approximately 30 percent of team exchanges one-third of these jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR setting. 7, 8, 9, 10, 11, 12 In multisite studies of intensive care units (ICUs), poor collaborative communication among nurses and physicians, among other specific factors, contributed to as much as a 1.8-fold increase in patient risk-adjusted mortality and length of stay. In the acute care setting, communication failures lead to increases in patient harm, length of stay, and resource use, as well as more intense caregiver dissatisfaction and more rapid turnover. The growing body of literature on safety and error prevention reveals that ineffective or insufficient communication among team members is a significant contributing factor to adverse events. 5 In a study of 2000 health care professionals, the Institute for Safe Medication Practices (ISMP) found intimidation as a root cause of medication error half the respondents reported feeling pressured into giving a medication, for which they had questioned the safety but felt intimidated and unable to effectively communicate their concerns. 4 When asked to select contributing factors to patient care errors, nurses cited communication issues with physicians as one of the two most highly contributing factors, according to the National Council of State Boards of Nursing reports. 1, 2, 3 A review of reports from the Joint Commission reveals that communication failures were implicated at the root of over 70 percent of sentinel events. The resultant toolkit provides health care organizations with the means to implement teamwork and communication strategies in their own settings.Ĭurrent research indicates that ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm. Analysis of 495 communication events after toolkit implementation revealed decreased time to treatment, increased nurse satisfaction with communication, and higher rates of resolution of patient issues post-intervention. Utilizing a pre-test/post-test design, baseline and post-intervention data were collected on pilot units (medical intensive care unit, acute care unit, and inpatient behavioral health units). The study setting was the 477-bed medical center of the Denver Health and Hospital Authority, an integrated, urban safety-net system. The specific aims included implementation of a structured communication tool a standardized escalation process daily multidisciplinary patient-centered rounds using a daily goals sheet and team huddles. The purpose of this study was to develop, implement, and evaluate a comprehensive provider/team communication strategy, resulting in a toolkit generalizable to other settings of care.
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