Communication Matters

Communication breakdowns were root causes in 70% of sentinel events reported to The Joint Commission.

Communication during patient handovers has been found to be ambiguous, non-standardized and problematic, which has contributed to adverse patient outcomes. Patient handovers are a potential point of vulnerability, but also a potential point of resilience.

In one Randomized Control Trial in Intensive Care, more patient handovers when there were different attending physicians on weekends (rather than 14 days straight) were associated with lower lengths of stay, better patient outcomes, and possibly reduced patient mortality. This is likely because the "fresh eyes" of the incoming physicians detected errors, as well as reducing burnout.

Point of vulnerability:

• Misunderstand system state
• Be unaware of significant data or events
• Be unprepared for impacts from prior events
• Fail to anticipate future events
• Drop or rework activities that are in progress
• Unwarranted shift in goals, decisions, plans

Point of resilience

• Detect erroneous assumptions, actions, etc.
• See opportunities to improve performance