For communication to be effective, it must be complete, clear, concise, and timely. However, various factors can interfere with the effective exchange of information. Healthcare risk management and patient safety literature contain numerous accounts of medical errors caused by communication failures.
Information may be missed, ignored, not recorded, or misdirected, but it is also possible to misunderstand the content, either because of hearing impediments (physiological or due to a noisy environment), language or cultural barriers, or due to incomplete information or failure to organize the information. Additional barriers to effective communication can include time constraints, organizational hierarchies, defensiveness, distractions, fatigue, workplace conflict, and workload (ACOG).
Strategies described in this article focus on communication among healthcare professionals. For additional strategies on effective communication between providers and patients, see
Supplementary Materials.
Patient Safety
Aggregate results from surveys of hospital staff to evaluate their organization's safety culture reveal the need to enhance strategies to improve communication, including teamwork across different levels of care, effective handoffs from one provider to another, and a culture of openness. Results from the 2022 Agency for Healthcare Research and Quality (AHRQ) survey of hospital patient safety culture indicate that although staff gave high scores to their organizations for fostering teamwork within care units (82% positive response), communication openness (76% positive response), communication about errors (73% positive response), other dimensions indicative of effective communication scored less favorably. For example, staff responses indicated that important information was left out during shift changes (63%) and during patient transfers to another unit (56%). (AHRQ "Hare et al.")
Claims and Lawsuits
Communication failures can have a significant financial impact on the organization if they lead to patient care errors that result in additional care needs and/or legal action.
As illustrated by an analysis of open and closed medical malpractice claims and lawsuits asserted between 2009 and 2013, the most recent data available as of this publication, communication breakdowns were a factor in 30% of the 23,658 analyzed claims. About a third of these cases were closed with payment with an average indemnity of $361,000. Cases resulting from miscommunication between providers were also more likely to result in payment than provider-patient miscommunication (CRICO).
Other findings from the analysis include the following (CRICO):
- Thirty-seven percent of all high-severity injury cases involved communication failures.
- Communication failure rates differ among care settings with 48% of failures occurring in ambulatory care settings, 44% in inpatient settings, and 8% in the emergency department.
- Fifty-seven percent of the cases involving communication failure were triggered by breakdowns in communication between two or more providers, 55% between providers and patients, and 12% involved both provider-to-provider and provider-to-patient communication failures. Common breakdowns between providers include miscommunication (26%), poor documentation (12%), and failure to read the medical record (7%).
- The total loss incurred amounted to $1.7 billion.
Regulations and Standards
Risk managers must ensure that their organization's policies and procedures addressing communication—from admission through discharge—comply with federal, state, and local requirements; case law in the organization's jurisdiction; and requirements of accrediting agencies used by the facility.
The Centers for Medicare and Medicaid Services (CMS)
CMS has regulations on verbal orders as part of its Conditions of Participation. Verbal orders can be given face to face or by telephone; however, texting is prohibited.
Verbal orders must be "dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations." (42 CFR § 482.24[c][2])
For more information, see
Communicating Medication Orders and the discussion
Verbal and Texting Orders.
The Joint Commission
With its Sentinel Event Alerts, National Patient Safety Goals (NPSGs), and accreditation requirements, the Joint Commission has supported numerous strategies for improved communication to enhance patient safety. One of the goals for 2023 is the improvement of effective communication among caregivers (Joint Commission "National").
Accreditation requirements address specific measures to improve communication, such as the following (Joint Commission "Comprehensive"):
- Maintain a list of prohibited abbreviations, acronyms, symbols, and dose designations that can be misinterpreted and cause errors. For more information, see
Medical Abbreviations, Initialisms, and Acronyms.
- Limit the use of verbal orders and require a repeat-back process to verify the information. For more information, see Communicating Medication Orders and the discussion Verbal and Texting Orders.
- Develop a process for handoff communication that provides the opportunity for discussion between the giver and receiver of patient information regarding the patient's condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. For more information, see the discussion
Handoff Communication.
DNV GL Healthcare
Accreditation requirements that address communication include (NIAHO):
- "Telephone or verbal orders are to be used infrequently and when used shall be accepted only by personnel authorized by the medical staff and in accordance with federal and state law."
- "Verbal orders shall be signed or initialed by the prescribing practitioner [and] shall be authenticated in accordance with federal and state law. If there is not state law that designates a specific timeframe for the authentication of verbal orders, the orders shall be authenticated within a time specified by organization policy."
- Avoid "dangerous abbreviations."
Leadership Support for Culture of Safety
Action Recommendation: Enlist the organization's senior leaders in demonstrating a commitment to a culture of safety.
Frequent and candid communication among providers and staff is a key characteristic of a culture of safety. The ability to speak up, voice concerns, and report near misses and errors in a healthcare organization without fear of reprisal has much to do with how well safety is embedded in the culture.
Therefore, effective communication starts with leadership demonstrating their commitment to a safety culture and taking necessary actions to attain a culture focused on open communication. Such actions include the following:
- Making patient safety an urgent organizational priority and communicating the organization's vision for safety excellence to staff
- Improving work environments and team functions so that providers and staff do not remain silent about issues that can interfere with patient safety, such as mistakes and intentional deviation from accepted practice
- Taking action when concerns are raised
- Focusing on systems analysis and processes rather than blaming individuals
- Recognizing patient safety successes
- Supporting and enforcing a code of conduct which prohibits behaviors that intimidate or belittle staff members (see
Sample Code of Conduct) - Providing sufficient staff and resources to promote the complete transfer of patient information with the next shift, to a covering colleague, or to another department or unit
- Adopting chain of command policies to give providers and staff clear lines of authority and paths of communication to follow for situations that may place patients at risk
- Modeling effective communication with all staff, using techniques promoted by the organization
For more detailed information, see
Culture of Safety: An Overview.
Teamwork
Action Recommendation: Support team-based approaches to care to enhance communication among team members, including addressing and eliminating disruptive behaviors.
Teambuilding and Training
Traditional hospital hierarchies that place nurses and other support staff at the bottom and physicians at the top can hinder communication. Effective communication is best achieved in an environment in which all providers and staff work together as a team.
Risk managers are uniquely positioned to promote teambuilding efforts in their facilities. Providers and staff should be given opportunities to enhance communication and teamwork skills, which can be done through completion of formal education and training programs. Risk managers should ensure that the training program provides learners with opportunities for active participation through role-playing, simulation, and discussion of effective and ineffective communication techniques. Case studies can be used to stimulate discussion about communication breakdowns.
Many healthcare facilities are already promoting teambuilding skills to break down hierarchies and foster effective communication skills. Drawing on the experience of other complex, high-risk industries, these healthcare facilities have used principle-based interventions and tool-based approaches that improve communication among team members. (Buljac-Samardzic et al.)
The two commonly used approaches for improving communication are
Crew Resource Management (CRM) and TeamSTEPPS.
Adopted from the aviation industry, CRM aims to take advantage of all available resources and information, including equipment, time, procedures, and people. It focuses on situational awareness, communication, adaptability, decision making, assertiveness, and leadership. (Gross et al.)
AHRQ and the U.S. Department of Defense have collaborated to develop a team training program called the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) system, an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals. The program is available online as a multimedia educational program for healthcare providers and organizations. The
TeamSTEPPS 2.0 curriculum includes an essentials course, seven fundamental modules, and an additional five supplemental modules for interdisciplinary team training to help reduce the incidence of medical errors. There is an alternate version as well for self-paced learning (AHRQ "About").
Chain of Command
While healthcare organizations can empower staff at all levels to speak up if there is any concern that an unsafe condition exists, conflicts can still arise. Because of this, healthcare facilities should establish chain of command policies to give providers and staff specific and clear lines of authority and paths of communication to follow for situations that may place patients at risk. For more information, see
Chain of Command.
Disruptive Behaviors
Behaviors that intimidate or belittle staff members and hinder open communication are counterproductive to a team environment and a culture of safety. These disruptive behaviors can occur at any level of the healthcare hierarchy (ISMP).
Healthcare organizations must strive to prevent or correct intimidating or disrespectful behaviors as they have a negative effect on the communication and collaboration necessary for safe patient care. The use of communication tools, discussed in
Structured Communication Tools, will be much less effective if staff are reluctant to speak up because they are threatened by intimidating behavior.
In addition, disruptive behavior is not only more common during prolonged, stressful situations (e.g., the COVID-19 pandemic) but can also contribute to provider burnout and higher staff turnover (Rehder et al.).
The Joint Commission has drawn attention to the issue with a Sentinel Event Alert and a Quick Safety, both updated in June 2021 (Joint Commission "Behaviors"; Joint Commission "Bullying").
For more information, see
Disruptive Practitioner Behavior.
Staff Perceptions about Communication
Action Recommendation: Assess staff perceptions of the quality of communication in their facilities and identify opportunities for improvement.
Organizations should periodically elicit feedback from staff to assess the quality of communication in their facilities and to identify opportunities for improvement. Given that effective communication is a key characteristic of a culture of safety, surveys designed to evaluate an organization's safety culture should include questions about the organization's approach to communication.
By conducting surveys at regular intervals, organizations can also monitor year-to-year changes in staff attitudes regarding communication and the effectiveness of any communication improvement initiatives.
ECRI's assessment tools provide a multidisciplinary perspective for identifying and managing risks related to this topic and other healthcare services. These web-based tools provide an easy-to-use, unbiased method to survey staff ranging from frontline nurses to organizational leaders. The tools generate reports, benchmarking data, and recommendations. For more information, email ECRI at clientservices@ecri.org
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Hospitals can use the AHRQ
Hospital Survey on Patient Safety Culture 2.0 to survey their staff on their attitudes regarding the organization's culture of safety. The survey has a section on communication within a unit or work area, which includes seven questions related to interprofessional communication (AHRQ "Hospital").
Other survey questions address characteristics that can foster effective communication such as the ability to work as a team and respectful treatment of staff.
Technology Solutions
Action Recommendation: Support technology that can transmit information across settings and among providers, but ensure it is planned, implemented, and maintained carefully.
When used properly, technology that transmits information across settings and among providers supports consistent and coordinated communication. Electronic health records (EHRs) can provide caregivers with readily accessible patient information, such as confirmation that a newly ordered medication was administered, lab tests were completed, or a do-not-resuscitate order is in place. Additionally, health information technology (IT), such as computerized physician order-entry systems, may reduce confusion regarding handwritten medical orders, orders for laboratory tests, and treatment orders.
If not planned and implemented carefully, however, health IT may jeopardize effective communication and patient safety.
For example, ECRI has identified data entry errors in the patient record as among the most frequent type of error associated with health IT (ECRI and the ISMP PSO). While these errors are sometimes the result of human factors (e.g., a provider inadvertently accessing the wrong patient record) these errors can also occur when software and system flaws cause the wrong data to be associated with a patient record.
Interoperability failures can also lead to patient harm. Failure to properly build the interfaces between two health IT systems can prevent important information from transferring from one record to another (e.g., a critical result from a laboratory test fails to transfer from a laboratory information system to the patient's EHR).
For more information, see
Electronic Health Records: Operational Issues.
Structured Communication Tools
Action Recommendation: Use structured communication tools to simplify and standardize communication practices.
Tools that simplify and standardize communication practices, as well as to serve as reminders, particularly during complex procedures, have been shown to enhance patient safety by reducing communication breakdowns which may lead to complications and adverse events (AHRQ "Implement").
Briefings, debriefings, safety huddles, repeat- and teach-back techniques, and checklists provide healthcare teams an opportunity to review a care plan or an approach to a particular procedure and ensure all team members are aware of pertinent information.
Team briefings during times of heightened patient-safety risk, such as at the beginning of a new shift or during patient transfers, can provide important information, communicate the plan of care, ensure that team member expectations are met, and prevent surprises (AHRQ "Implement"). See AHRQ's
Conducting a Morning Briefing for a tool that can be adapted for use during briefings.
Debriefings—a key feature of high-performing teams—provide structured formats to evaluate and improve team performance. Debriefings should be done regularly—not just when things go poorly—and built into the team workflow (Edwards et al.).
Safety huddles provide opportunities for staff to exchange patient information, make and share plans to ensure coordinated patient care, and address particular issues as a team (AHRQ Shaikh).
Repeat- and teach-back communication ensures staff members understand instructions and information. Repeat-back communication occurs when one provider shares information (e.g., patient vitals, medication doses), the second provider acknowledges and repeats the message verbatim, and then the first provider confirms the information. Teach-back communication differs slightly in that the second person is asked to describe in their own words what was shared. See
Teach-Back: Sample Scripts.
Checklists may be used to improve team communication and reinforce safety practices; however, it is important to guard against completing checklists quickly or carelessly. Therefore, organizations should judiciously identify which processes and procedures may be guided by a checklist in order to prevent checklist fatigue. All activity should cease and everyone on the team should be attentive while the elements of the safety checklist are completed. This enables anyone with questions, concerns, or information about the patient's safety to speak up and provide input before a process or procedure commences (Russ et al.).
Handoff Communication
Action Recommendation: Adopt standardized handoff processes to communicate essential patient information during care transitions.
Patient handoffs are important aspects of care coordination. A handoff is the transfer of patient information, as well as responsibility, from one clinician to another during transitions across the healthcare continuum. The process should include an opportunity for discussion between the transferring and the receiving clinician, as well as the opportunity to ask questions and clarify information (ACOG).
Patient confidentiality must be protected during handoff discussions. Only those involved in direct patient care should be able to hear or view protected health information. For more information, see The HIPAA Privacy Rule.
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Handoffs can occur multiple times each day for patients—during shift changes, when a patient transfers to a different level of care, when a patient is sent to another department or unit, and when a physician transfers responsibility for caring for a hospitalized patient (referred to as a "sign out" procedure) to another physician. Consequently, thousands of patient handoffs occur daily in every hospital.
However, a study of malpractice claims from 2001 to 2011 showed that 49% of claims were associated with communication failures. Of these claims, 40% included a failed handoff, the majority of which were identified as potentially avoidable by using a handoff tool (Humphrey et al.). The Joint Commission has issued a sentinel alert as a result of patient safety risks due to inadequate handoff communications (Joint Commission "Inadequate").
Hospitals must have a process in place for healthcare providers to share and receive information about patients. This process should include (ACOG):
- Interactive communication
- Limited interruptions
- A process to verify information
- The opportunity to review information
SeePolicy and Procedure Builder: Patient Handoffs and Transitions of Care for a sample policy.
The following information should be included during a handoff exchange:
- Patient identifying information (e.g., name, age, sex), date of admission, and location
- Diagnosis
- Results from physical examination
- Current condition
- Changes in condition and treatment
- Patient's code status, medical and surgical history, active medications, and allergies
- Recent and pending laboratory tests
- Immediate patient care concerns
- Recommendations
For more information, seeHandoff Communication Strategies.
A consistent format for handoff reports helps staff members accurately record and recall information. One such format that can be used is the SBAR (Situation, Background, Assessment, and Recommendation) technique. According to SBAR, the caregiver conducts the handoff by addressing the following (IHI):
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Situation—define what is going on with the patient
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Background—keep information brief, relevant, and on point
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Assessment—summarize what the caregiver found
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Recommendation—provider recommendations or actions for the receiver to complete
SeeSBAR Communication Tool for a sample script andSample Handoff Communication Template for a sample form, both of which follow the SBAR technique and may be used by providers during handoffs.
Another mnemonic tool to structure handoffs is I-PASS the BATON. The tool prompts the following exchange of information (AHRQ "Pocket"):
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Introduction—introduce caregiver and their role
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Patient—provide patient's name, age, sex, and location
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Assessment—present chief complaint, vital signs, symptoms, and diagnosis
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Situation—describe current status, circumstances, code status, recent changes, and response to treatment
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Safety concerns—identify critical lab values, socioeconomic factors, allergies, and alerts, such as falls risk and isolation precautions
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Background—describe comorbidities, current medications, previous episodes, and family history
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Actions—identify actions taken or required and provide brief rationale
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Timing—address level of urgency, timing, and prioritization of actions
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Ownership—identify care team responsible for patient and patient/family responsibilities
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Next—discuss plan for patient, what will happen next, anticipated changes, and contingency plans
A third handoff mnemonic, I-PASS, focuses on key information (Blazin et al.):
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Illness severity
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Patient summary
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Action list for the next team
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Situation awareness and contingency plans
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Synthesis and "read-back" of the information
SeeGeneral Handoff Report Form for a tool that can be used when transferring a patient to another unit or during shift changes, andBrief Relief Report Form for a tool that can be used when temporarily turning over responsibility for a patient's care during lunch or another short break.
Distractions
Action Recommendation: Minimize interruptions and distractions during information exchange.
Interruptions and distractions occur frequently in healthcare institutions, and the effects of interruptions can be detrimental to effective communication (Kellogg et al.). Providing a well-lit and quiet place for communication to take place—particularly during handoffs—will help to minimize distractions and ensure a successful exchange. SeeReality Check: Quiet on Set! for a cartoon depicting the risks of communicating important patient information in a noisy environment.
Borrowing from the aviation industry, some organizations have adopted the idea of a "sterile cockpit" during the transfer of patient information. Just as the cockpit crew is prohibited from performing nonessential duties and activities during key phases of flight, healthcare providers must focus their attention on exchanging essential patient information and limit interruptions during the handoff (Connor et al.). The transfer of patient information should take priority over all other duties except emergencies.
High noise levels in busy areas, such as the operating room and emergency department, can impair staff communication and negatively affect patient safety (Anzan et al). Risk managers should work with their organizations to identify and implement strategies to reduce noise in these busy environments (Peng et al.) or should consider designating an area (e.g., conference room) for these exchanges to take place (ACOG).
Even handheld devices intended to promote communication can be a source of distraction. One study found that healthcare providers who use smartphones during attending rounds can become distracted during moments of important information transfer (Katz-Sidlow et al.). While an outright ban on smartphone use is likely impractical—and possibly even counterproductive, since these devices offer many legitimate benefits—effective policies regarding smartphone use are essential. The success of such policies will depend on support from leadership and cooperation from staff. For more information, see
Personal Electronic Devices in Healthcare.
Verbal and Texting Orders
Action Recommendation: Limit verbal orders to avoid errors; when verbal orders are unavoidable, require specific practices to minimize mistakes.
CMS allows the use of texting as a communication tool restricted to the exchange of information through a secure platform but prohibits texting patient orders (CMS). However, concerns about the Health Insurance Portability and Accountability Act (HIPAA) violations will need to be considered. For more information see The HIPAA Security Rule.
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Verbal and telephone orders for medications and medical care are susceptible to error. Consider the environment of a busy clinical setting—caregivers coming and going, multiple conversations being held concurrently, the sounds of equipment operating, telephones ringing, and alarms sounding. Further, different accents, dialects, and pronunciation can make communicating important information even more challenging. All of these factors contribute to the possibility that orders or test results communicated verbally or by telephone will be heard incorrectly or misunderstood. This is particularly true with orders for medications that have sound-alike drug names.
Verbal orders should be avoided, when possible, as required by Joint Commission accreditation standards. When it is highly impractical or impossible for the prescriber to write down orders or enter them into a computerized provider order-entry system at the time they are given, verbal or telephone orders may be the only alternative. The receiver of the order must then write down the verbal or telephone orders as they are given and read back the information as it is written for confirmation (Joint Commission "Comprehensive"). The ordering practitioner must also promptly authenticate, date, and time the order (42 CFR § 482.24[c][2]).
Methods to demonstrate that the verbal order was written down and read back vary among healthcare organizations. Some opt to have the receiver of the orders document "verbal order read-back" in the patient medical record, while others use forms designed to capture the verbal order read-back process with a check-off and signature.
It is important that compliance with the read-back process be monitored through observation and/or record audits.
For more information, see
Communicating Medication Orders.
Test Results Reporting
Action Recommendation: Optimize practices for reporting test results, including special procedures for critical tests and critical results.
Patient treatment delays and failures to follow up on important abnormal diagnostic tests have occurred because of communication delays or breakdowns in the reporting of test results. Delays, failures, and inaccuracies in reporting test results place patients at risk for treatment delays, omissions, and errors.
To address potential test result communication breakdowns, the Joint Commission established an NPSG to improve communication among caregivers that requires accredited organizations to report critical results of tests and diagnostic procedures on a timely basis (Joint Commission "National").
The Joint Commission requires the reporting of critical results of tests and diagnostic procedures on a timely basis. Critical results are defined as those that "fall significantly outside the normal range and may indicate a life-threatening situation." (Joint Commission "National")
The Joint Commission requires facilities to develop procedures that address the following (Joint Commission "National"):
- Definitions for critical results of tests and diagnostic procedures
- By whom and to whom critical results of tests and diagnostic procedures are reported
- Acceptable time lapse between the availability of and reporting of critical results
Organizations also need a process for implementing their reporting procedures as well as a mechanism to evaluate the timeliness of reports. (Joint Commission "National")
The procedures should address measures for reporting results to a backup healthcare provider if the ordering clinician is unavailable. Additionally, the procedures should incorporate repeat-back practices if the results are reported verbally. Refer to the discussion Verbal and Texting Orders for information on repeat-back methods.
Risk managers should also ensure organizational policy addresses the communication of other test results, including normal and abnormal (a test result that requires the ordering provider's attention, but is not urgent or life-threatening). Test turnaround times should be periodically monitored and evaluated, and risk managers should investigate instances in which all results—normal, abnormal, and critical—are not properly communicated, and implement improvements when needed.
For more information see Test Tracking and Follow-Up.