Using incident reports to assess communication failures and patient outcomes.
Communication failures are a common underlying factor in adverse events. Although the relationship between communication failures and safety has been best studied in the operating room, this issue likely contributes to safety problems in all settings of care. Investigators examined incident reports at an academic medical center to characterize how communication problems contribute to adverse events. Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying that situational awareness was not achieved—were among the most common types of communication problems identified. The authors point out that while structured communication tools (such as the I-PASS handoff tool) can improve the accuracy and completeness of information transfer, they are not well suited to improving communication in clinically ambiguous situations. Communication problems most often led to delays in care without physical harm, highlighting the difficulty of measuring communication issues compared to other types of safety events. A WebM&M commentary discussed a series of communication errors that led to a child's death.