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We welcome your feedback, comments and suggestions. Please feel free to contact
us if you have a question or to send us your ideas for improving this site.
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Vice President of Healthcare Risk Services
Tom Snyder x5852
Manager, Healthcare Risk Services
Phyllis DeCola x5897
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Risk Management:
Failure to Communicate
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Verbal communication miscues are most responsible
One study conducted in a Pediatric Intensive Care Unit revealed:
- Verbal communications between physicians and nurses were observed only in 2% of the activities recorded during a 24 hour observation period
- Verbal communications between physicians and nurses were responsible for 37% of medical errors
- The “Danger Zone” for verbal communication errors coincided with physician rounds and nursing changes of shift
- The impact of failed communication included incorrect decisions and inappropriate actions
- Physicians and nurses shared equally in terms of the severity of “verbal” communication errors
- The severity of errors included very critical ones for both groups in roughly equal proportions. Donchin, Y, Gopher, D, Badihi, Y, Biesky, M, Sprung, CL, Pizov, Cotev, S, Qual Safe Health Care; 2003; 12:143-148
The common risk factors in verbal communication include the following:
- No communication (as a result of either anxiety and/or intimidation which may occur not only between physicians and nurses, but other healthcare practitioners including other physicians lower on the medical “hierarchy” who believe their careers may be affected)
- Failure to communicate in a manner that can be readily understood with respect to its purpose (sometimes known as “hint and hope” communication)
- Not hearing correctly what was said
- Not understanding what was said
- Misinterpreting what was said
- Forgetting what was said
Now that communication miscues have been diagnosed as the cause of many, if not most, medical errors, what treatments are available?
Three keys to more effective communication
- All parties must be knowledgeable and in agreement as to their respective communication expectations and responsibilities.
- Avoid passing along critical information orally. If verbal communication is essential, then write down, and read back what you thought you heard. Verbal orders, as a rule, should be avoided, if at all possible. When they are unavoidable, they must be signed and dated within 24 hours by the physician issuing the order.
- Ensure that decision makers are reliably provided with all relevant and necessary information so that appropriate decisions may be reached. A tool used to promote this manner of communication is known as “SBAR.” An example of how SBAR can work in a healthcare setting may be found in: Communication at Transitions or Transfers of Care: Challenges and Strategies—A Self-Learning Module for Professionals; Children’s Hospitals and Clinics of Minnesota; Minneapolis/St. Paul, MN (2005).
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