Executive Summary

Communication is the crux of safe healthcare. The ability to transmit information between patients and providers and among caregivers is central to the provision of safe, quality medical care. However, the increasingly complex healthcare environment can complicate the communication process and hinder the information exchanges necessary for optimum care.

Communication breakdowns in healthcare can occur in various ways. For example, communication can fail during patient handoffs (i.e., transfer of responsibility and accountability for patients between caregivers, such as during a change of shift or on patient discharge from the hospital). Communication breakdowns can also occur within the team of caregivers treating a patient in a particular setting (e.g., the OR), between a patient's attending physician and consulting physicians, or even between the physician and the patient. Communication lapses can also include the family members involved in the patient's care.

When communication fails, errors can occur, sometimes resulting in patient injury or death. Communication was cited as a root cause in 61% of sentinel events re-ported to the Joint Commission from 2011 through June 2013, surpassing other commonly identified issues such as care planning, patient assessment, and continuity of care (Joint Commission "Sentinel"). Refer to Figure. Communication Breakdowns among Top Root Causes for Sentinel Events Reported to the Joint Commission, 2011 through June 2013 to see where communication ranks as a root cause for reported sentinel events.

Communication breakdowns are also a leading cause of medical malpractice claims and lawsuits, as illustrated in Figure. Communication Breakdowns Factor into More Than 40% of Malpractice Cases. Of the 1,160 medical malpractice claims and lawsuits asserted from 2006 through 2010 against clinicians and organizations covered by medical professional liability insurer CRICO (Cambridge, Massachusetts), 42% of the cases reflected communication breakdowns (Hoffman and Raman). CRICO covers Harvard medical institutions and affiliated physicians.

Given the close link between patient safety and effective communication, risk managers should work with facility leaders to assess and monitor the quality of communication in their organizations. Multiple initiatives to improve communication are available from quality and safety agencies. In fact, the Agency for Healthcare Research and Quality's (AHRQ) 2013 updated evidence report identifying patient safety practices for either immediate adoption or consideration lists several strategies that can enhance communication, including the following (Shekelle et al.):

  • Using checklists
  • Prohibiting hazardous abbreviations that are often misunderstood
  • Supporting team training
  • Reconciling medications across care settings
  • Obtaining patients' informed consent to improve their understanding of procedure risks
  • Using simulation exercises for patient safety efforts
  • Implementing computerized provider order entry (CPOE) systems

Utilizing evidence-based practices such as these to improve quality and patient safety is one of the high-priority strategies recommended by the American Hospital Association in its report Hospitals and Care Systems of the Future.

This Guidance article* highlights the consequences of communication failures on patient care to underscore the need for effective communication strategies in healthcare organizations. Strategies described in this article include structured communication practices, such as handoffs; limits on verbal orders; policies for critical test results reporting; team training; limits on noise and distractions; technology solutions; patient and family engagement; and staff education and training. Given that communication is fundamental to risk management, quality, and patient safety, recommendations for improving communication are spread throughout Healthcare Risk Control (HRC). Refer to Resource List for additional information about tools to support many communication improvement initiatives, as well as guidelines and educational resources from medical and nursing associations on communication improvement strategies.

Action Recommendations

  • Assess staff attitudes about the quality of communication in their facilities, and identify opportunities for improvement.
  • Enlist the organization's senior leaders in demonstrating a commitment to a culture of safety.
  • Use structured communication tools (e.g., checklists, briefings, repeat-back techniques) to simplify and standardize communication practices.
  • Adopt handoff processes to communicate essential patient information during care transitions such as shift changes.
  • Limit verbal orders to avoid errors; when verbal orders are unavoidable, require specific practices to minimize mistakes.
  • Adopt standard practices for reporting critical test results and values.
  • Support team-based approaches to care to enhance communication among team members.
  • Minimize interruptions and distractions when information is being exchanged.
  • Support technologies that can transmit information across settings and between providers, but ensure they are planned and implemented carefully.
  • Engage patients in their care while following strategies to ensure they understand the information provided to them.
  • Provide education and training on effective communication for physicians and staff members involved in patient care.

* HRC gratefully acknowledges Kathleen Shostek, RN, ARM, B.B.A., FASHRM, CPHRM, senior healthcare risk management consultant, Sedgwick Claims Management Services, Inc., as a reviewer of this Guidance article.

Who Should Read This

The Issue in Focus

​Communication Breakdowns among Top Root Causes for Sentinel Events Reported to the Joint Commission, 2011 through June 2013

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Communication Breakdowns among Top Root Causes for Sentinel Events Reported to the Joint Commission, 2011 through June 2013 

Note: The majority of events have multiple root causes.

Source: Joint Commission. Sentinel event data: root causes by event type, 2004-Q2 2013 [online]. 2013 Sep 20 [cited 2013 Sep 30]. http://www.jointcommission.org/assets/1/18/

Communication Breakdowns Factor into More Than 40% of Malpractice Cases

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 ​Communication Breakdowns Factor into More Than 40% of Malpractice Cases

Source: Hoffman J, Raman S. Communication factors in malpractice cases [online]. 2012 Mar 15 [cited 2013 Jul 31]. https://www.rmf.harvard.edu/Clinician-Resources/Article/2012/Insight-Communication-Factors-in-Mal-Cases 

Communication is the exchange of information between individuals, groups, and organizations. It may entail a physician and nurse discussing a change to a patient’s medication dose, a surgical team reviewing a plan for surgery before beginning the procedure, or a hospital communicating to a rehabilitation facility about the discharge plans for a patient who requires physical therapy following a hip replacement procedure.

Communication can occur as a verbal, written, or electronic exchange; it can also be a combination of any of these approaches. Communication also entails nonverbal exchanges, such as facial expressions and body language.

For communication to be effective, it must be complete, clear, concise, and timely (AHRQ “TeamSTEPPS”). In healthcare settings, various factors can interfere with the effective exchange of information. The healthcare risk management and patient safety literature contains numerous accounts of medical errors caused by communication failures. In a case from AHRQ’s online case study review, WebM&M, important information about a patient’s critical test results failed to reach the patient’s provider. The results were reported to the busy emergency department (ED) environment after the patient had been transferred to another level of care. (Beach)

The patient was seen in the ED and admitted to the hospital following a shift change in the ED. The communication between the ED physicians going off duty and coming on duty was vague and incomplete, consisting of a report that the patient was “admitted,” with care transferred to the internal medicine service. A platelet count had been ordered, but the result was pending at the time of transfer from the ED. The result, which was critically low (4,000/mm3), was telephoned to the ED secretary four hours later, but it was unclear whether this information was ever relayed to either the ED physician or the internal medicine physician. Eighteen hours later, during morning rounds, the low platelet count was noted by the internist, and the patient was transferred to the intensive care unit with a diagnosis of thrombotic thrombocytopenic purpura. Plasma exchange was undertaken; however, the patient’s condition deteriorated and she died. (Beach)

The frenetic pace of activity in the ED, inadequate communication about the patient’s clinical condition during a shift change, and a breakdown in the reporting of critical test results most likely contributed to this sentinel event. With any communication-related event, a wide range of factors can influence the breakdown, including the following (Cvetic; ACOG; AHRQ “TeamSTEPPS”):

  • A distracting and noisy environment
  • Fatigue
  • Heavy workload
  • Varying communication styles
  • Language and cultural differences
  • Conflicts
  • Hierarchical approaches that inhibit the transfer of information between individuals, such as between a physician and a nurse
  • Information gaps during care transitions
  • Lack of information verification

Patient Safety

Risk managers and healthcare executives are aligned in viewing communication breakdowns as a top barrier to improved patient safety. A 2013 report on patient safety summarized findings from a survey of hospital executives and risk managers on behalf of insurer AIG. According to the report, 42% of healthcare executives and 55% of risk managers identified poor communication, along with lack of teamwork and a negative organizational culture, as the greatest barrier to improving patient safety. Additionally, nearly 68% of senior executives and 75% of risk managers identified staff communication as their top challenge in maximizing patient safety in their hospitals. (AIG)

Aggregate results from surveys of hospital staff to evaluate the organization’s safety culture reveal the need to improve many of the strategies that promote good communication—teamwork across different levels of care, effective handoffs from one provider of care to another, and a culture of openness. Results from the most recent AHRQ surveys of hospitals’ patient safety cultures, conducted in 2012, indicate that although staff give high scores to their organizations for fostering teamwork within care units (80% positive response), other dimensions indicative of effective communication scored less favorably, as follows (AHRQ “Chart 5-1”):

  • Communication openness (62% positive response)
  • Teamwork across units, as opposed to within care units (58% positive response)
  • Handoffs and transitions (45% positive response)

Patients also equate good communication with safety. Although error is typically described as a deviation from the standard of care, patients who experience a medical error frequently describe the error as a consequence of a communication gap. In one study of 30 patients who were asked to tell their stories of medical error, the patients identified lack of communication, missed communication, or poor interpersonal styles of communication as the reasons for the errors (Kooienga and Stewart).

Claims and Lawsuits

​Closed Malpractice Cases with Payment: 23% Higher If Communicatoin-Related

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 Closed Malpractice Cases with Payment: 23% Higher If Communication-Related

Note: Based on 1,163 malpractice cases closed 2006 through 2010 by medical professional liability insurer CRICO (Cambridge, Massachusetts); 532 of the closed cases were communication-related.

Source: Hoffman J, Raman S. Communication factors in malpractice cases [online]. 2012 Mar 15 [cited 2013 Jul 31]. https://www.rmf.harvard.edu/Clinician-Resources/Article/2012/Insight-Communication-Factors-in-Mal-Cases

Communication failures can have a significant financial impact on the organization if they lead to patient care errors that not only result in additional care needs but also lead to legal action. As illustrated by the CRICO analysis of open and closed medical malpractice claims and lawsuits, communication breakdowns were responsible for almost half of the claims asserted (484 of 1,160 malpractices cases). The average payment for communication-related cases resolved with payment from 2006 through 2010 was $768,000, which, as illustrated in Closed Malpractice Cases with Payment: 23% Higher If Communication-Related, was higher than the average payment for all of the insurer’s malpractice cases that were closed with payment over the same time period. Typically, about one-third of the insurer’s cases are resolved with payment.

Other findings from the CRICO analysis of the 484 communication-related cases include the following:

  • Sixty-nine percent of the cases alleged gaps in information provided to patients.
  • Forty percent of the cases were triggered by breakdowns in communication between two or more providers (some of the cases allege both provider-to-provider and provider-to-patient communication failures).
  • Defendants named in communication-related cases were typically the medical staff (named in 44% of the cases) or the organization (named in 30% of the cases).

To assist risk managers in highlighting for staff the importance of effective communication, HRC has prepared a one-page handout summarizing this data and other findings from the analysis; Handout: Communication-Related Medical Malpractice Cases.

Regulations and Standards

Various federal regulations and accrediting standards promote effective communication among caregivers and staff, as well as between caregivers and patients. For example, federal regulations that specify the requirements for hospitals to participate in the Medicare program, as well as interpretive guidance for the regulations, address communication in areas such as medication safety, informed consent, care coordination, and discharge planning. Examples of requirements in the Conditions of Participation (CoPs) that are designed to improve communication are as follows:

  • Limit verbal orders, which can increase the risk of miscommunication that can contribute to a medication or other type of error (42 CFR § 482.23[c][3][i]). (For more information about best practices for verbal orders, refer to the discussion Verbal Orders, as well as the Guidance Article Medication Safety.
  • Implement policies for read-back verification of every verbal order to ensure the order is understood (CMS).
  • Standardize prescribing and communication practices to minimize drug errors (e.g., avoid dangerous abbreviations, use preprinted order sheets whenever possible, ensure patient-specific information is readily accessible to all individuals involved in providing pharmaceutical care) (42 CFR § 482.25; CMS).
  • Establish communication procedures to ensure integration of inpatient and outpatient services to provide continuity of care (42 CFR § 482.54[a]; CMS).
  • Establish communication procedures to ensure integration between the hospital ED and other hospital services (42 CFR § 482.55[a]; CMS).

Similarly, measures to enhance communication permeate accreditation standards. For example, 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. Within its accreditation program, the leadership standards, for instance, call for effective communication that is timely, accurate, and usable by those who need it, including staff, licensed independent practitioners, patients, families, and others. Other accreditation requirements address specific measures to improve communication (some of which are also covered in the Medicare CoPs), 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 (refer to the Guidance Article Medical Abbreviations.
  • Limit the use of verbal orders and reports, and require a read-back process to verify the information.
  • Develop a process for handoff communication that provides for 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 (refer to Handoff Communication for more information).
  • Provide patients with information that is tailored to each patient’s age, language, and ability to understand (refer to the Guidance Article Culturally and Linguistically Competent Care, for more information on Joint Commission standards addressing patients’ linguistic and cultural needs).

Several of these accreditation requirements (i.e., listing prohibited abbreviations, limiting verbal orders, and incorporating handoffs) started as NPSGs, which are updated annually to address specific areas of concern in patient safety. Indeed, effective communication is a prerequisite for meeting many Joint Commission NPSGs, such as addressing reporting of critical results of tests and procedures, medication reconciliation, and prevention of wrong-site, wrong-procedure, and wrong-person surgery (Joint Commission “Hospital”).

The Joint Commission also requires that the medical staff’s credentialing criteria for licensed independent practitioners consider the individual’s communication skills. This provision is in concert with the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, which list communication skills with patients and their family members, as well as healthcare team members, as one of six general competencies required of medical staff members.

Given that best practices for communication are interspersed throughout regulations and standards affecting hospitals, risk managers must ensure that their organization’s policies and procedures addressing communication—from admission through discharge—are in compliance with federal, state, and local requirements, case law in the organization’s jurisdiction, and requirements of accrediting agencies used by the facility. Although effective communication underpins many of an organization’s policies and procedures, the following Action Plan describes some of the essential practices for good communication. In keeping with risk management documentation practices, the patient’s medical record must objectively document any information exchange among physicians and other healthcare providers, as well as the patient.


Staff Attitudes about Communication

Action Recommendation: Assess staff attitudes about 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 include questions about the organization’s approach to communication. By conducting the surveys at regular intervals, the organization can also monitor year-to-year changes in staff attitudes about communication and the effectiveness of any communication improvement initiatives.

At least six items related to communication at the unit level are included in AHRQ’s hospital survey on patient safety culture. The survey questions ask hospital staff about the quality of communication based on the following (AHRQ “Hospital”):

  • Feedback on changes made based on event reports
  • Ability to speak up about something that may negatively affect patient care
  • Ability to question the decisions or actions of someone in authority
  • Provision of information about errors that occur in their work unit
  • Discussion of the prevention of errors in the future
  • Ability to ask questions when something does not feel right

Other questions address facility characteristics that can foster good communication: ability to work as teams, respectful treatment of staff, and exchange of information across hospital units.

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 caregivers and across organizational levels 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 excellence in performance. Such actions include the following:

  • Improving work environments and team functions so that caregivers do not remain silent about issues that can interfere with patient safety, such as intentional deviation from accepted practice, incompetence, and mistakes
  • Prohibiting behaviors that intimidate or belittle staff members and hinder open communication
  • Providing sufficient staff and resources to promote the complete transfer of patient information with the next shift or to a covering colleague
  • 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, using techniques promoted by the organization, in encounters with staff

For more detailed information about assessing and implementing a culture of safety, see the Guidance Article Culture of Safety.

Structured Communication Tools

Action Recommendation: Use structured communication tools (e.g., checklists, briefings, repeat-back techniques) to simplify and standardize communication practices.

Tools that simplify and standardize communication practices, as well as serve as reminders, particularly during complex procedures, have been shown to enhance patient safety by reducing the occurrence of communication breakdowns that can lead to complications and adverse events. Structured tools can prompt staff to communicate pertinent information about the patient or to complete essential tasks that could be overlooked if staff relied only on memory. Structured tools used for patient handoffs, for example, remind staff of specific information that must be communicated: pertinent demographic information, a brief history and results of any physical examinations, active problems, medications and allergies, pending test results, ongoing or anticipated therapy, key patient values and preferences, and other critical information. Examples of handoff tools are reviewed in the discussion Handoff Communication.

Risk managers should support the use of structured communication techniques, such as checklists, briefings, debriefings, and handoffs, which are highlighted in Table. Structured Communication Tools. Examples are further described in this discussion.


In the OR environment, many surgical teams use a threepart checklist to improve team communication and reinforce OR safety practices. Called the World Health Organization (WHO) Surgical Safety Checklist, the check-list reminds the surgical team to review basic but critical steps that sometimes get overlooked at three different points: before anesthesia is started, before the surgeon begins cutting, and before the patient leaves the OR.

Implementation of the 19-item surgical safety checklist reduced complications and deaths associated with surgery, according to a study in the New England Journal of Medicine (Haynes et al.). The study, which included eight hospitals from eight global cities, found that the rates of death (1.5%) and complications (11.0%) before implementation of the checklist were greatly reduced (to 0.8% and 7.0%, respectively) among patients at least 16 years of age who were undergoing noncardiac surgery. Elements of the surgical safety checklist include verification of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery. Refer to Resource List for information on obtaining the WHO Surgical Safety Checklist online.

It is important to guard against allowing completion of a checklist to become perfunctory. 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 procedure commences. The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery combines the use of a checklist and a “time out” so that the team members can focus on actively confirming the patient identify, the site of operation, and the procedure to be done (Joint Commission “Hospital”). For more information, refer to the Guidance article Wrong-Site Surgery.

Another freely available checklist is a daily goals checklist, used during morning and evening rounds of care, to prompt the care team to review what needs to be accomplished for the day to ensure the discharge goals for the patient are safely met. The daily goals checklist is included in the Comprehensive Unit-based Safety Program (CUSP) toolkit, which was developed at the Johns Hopkins Hospital with funding from AHRQ, to promote safe patient care using teamwork and effective communication. Information about accessing the CUSP toolkit and the daily goals checklist from AHRQ’s website is available in Resource List. In addition see, the ICU Patient Safety: Daily Goals.

Briefings, Debriefings, and Huddles

Briefings, debriefings, and huddles provide healthcare teams an opportunity to briefly review a care plan or an approach to a particular procedure to ensure all team members are collectively aware of pertinent information. For example, in the OR environment, the surgical safety checklist can be used along with a preoperative briefing to convey patient and procedural information and to give team members an opportunity to voice concerns and clarify misunderstandings before proceeding. In one study, presurgery briefings involving all members of the surgical team and the use of a checklist reduced incidences of communication failures and facilitated proactive team communication (Lingard et al.).

Briefings among team members can also be used at other high-risk times, such as at the beginning of a new shift and during patient handoffs between departments. Team members use the briefings to relay important information, communicate the plan of care, ensure that team members’ expectations are met, and prevent surprises. A morning briefing tool, available from AHRQ, promotes effective communication between two or more people, such as a night nurse and an incoming physician, before patient rounds in an inpatient unit. The briefing tool prompts a dialogue about important information concerning patients on the unit by addressing the following questions:

  • What happened overnight that the incoming provider needs to know about?
  • Where should the incoming provider begin rounds (e.g., Does a patient need immediate attention? Will a patient be transferred from the unit?)?
  • What issues affecting patient safety are anticipated (e.g., equipment availability, staffing, provider skill mix)?

Refer to Resource List for information on accessing the tool online. The briefing tool, which is included in the CUSP toolkit from AHRQ, is intended to be used with the daily goals checklist to promote teamwork and communication on care units.

Debriefings, a key feature of high-performing teams, provide a structured format to evaluate and improve team performance. Debriefings should be done regularly—not just when things go poorly—and built into the team workflow. For example, surgical team members should conduct a debriefing after every surgical case and procedure. (Shostek and Webster)

Questions to answer during a debriefing include the following (Shostek and Webster):

  • What went well?
  • What should be done differently next time?
  • What are the lessons learned and to be shared?
  • What glitches were identified that need to be fixed, including system, equipment, and process issues?

In addition to briefings and debriefings, healthcare organizations have adopted the idea of “safety huddles” for staff to exchange patient information, make and share plans to ensure coordinated patient care, or address a particular issue as a team. Studies have shown that huddles can improve patient safety by promoting efficient exchange of information, providing a venue to raise concerns, and enhancing working relationships (Goldenhar et al.). For example, during a 5- to 10-minute shift-change meeting, outgoing staff can report any critical patient information that the incoming staff should know, including code status, diagnosis, precautions, telemetry status, scheduled tests, falls risk, safety issues, and a general care plan for the day. Staff at one hospital also used the shift-change safety huddle as an opportunity to review educational opportunities, such as in-services, that are offered during the day (Chapman).

Repeat Back and Teach Back

Repeat- and teach-back communication lets staff check whether a person, such as another staff member or a patient, understands instructions and information. For example, a unit nurse might repeat back instructions from a patient’s physician to verify understanding, clarify as needed, and review important information one more time. Given the importance of repeat-back practices to prevent misunderstandings, Joint Commission accreditation standards and CMS CoPs reinforce this practice. The Joint Commission’s accreditation standards, for example, require caregivers to repeat back any verbal order or verbal report of a critical test result to verify the information (see the discussion Verbal Orders for more information about these requirements).

Engaging patients in teach-back processes can also prevent communication breakdowns between provider and patient. For example, having patients teach back what they understand after a new medication is prescribed or after informed consent discussions has been shown to improve their overall comprehension. Patients might even be asked to demonstrate what they have learned if operation of a device, such as a glucose meter, is involved. A study to evaluate patients’ comprehension following informed consent discussions about their upcoming surgical procedure found that the mean comprehension in the group asked to teach back was significantly higher (71%) than the mean comprehension in the group that was not asked to teach back (68%) (Fink et al.). The study’s researchers note that providers spent an average of 2.6 minutes longer to obtain informed consent using the teach-back method, but most indicated that they felt the additional time was acceptable to enhance the surgical informed consent process.

Keeping in mind the hours, weeks, months, and even years that may be involved in defending litigation for lack of informed consent, risk managers should encourage providers to take a few extra minutes to ensure patient understanding. For additional information about teach-back approaches for patients, refer to the Guidance Article Health Literacy.

Handoff Communication

Action Recommendation: Adopt handoff processes to communicate essential patient information during care transitions such as shift changes

The Institute of Medicine noted in its report Crossing the Quality Chasm that when information necessary for the care of a patient is missed, forgotten, or lost during transitions (i.e., handoffs), safety is compromised (IOM). Patient handoffs occur multiple times each day for every patient—during shift changes, when a patient transfers to a different level of care, when a patient is sent to another department for a procedure such as diagnostic imaging or physical therapy, and when a physician transfers responsibility (referred to as a “sign out” procedure) for caring for a hospitalized patient to another physician. Consequently, thousands of patient handoffs occur daily in every hospital. One teaching hospital calculates that as many as 4,000 provider-to-provider handoffs occur daily at the hospital (Vidyarthi).

Thorough and effective handoffs foster patient care quality and safety. Once an NPSG to improve the effectiveness of communication among caregivers, handoff processes are required by Joint Commission accreditation standards. Hospitals must have a process in place for healthcare providers to receive or share information about patients when they are referred to either internal or external providers for care, treatment, and services. (Joint Commission Comprehensive)

During a handoff, patient-specific information is conveyed from one caregiver to another or from one level of care to another. This information includes the patient’s current condition, recent changes in condition, ongoing treatment, pending test results, and possible changes or complications that might occur (refer to Handoff Essentials for a list of information to include in the exchange). The provider taking on responsibility for a patient’s care has a chance to ask questions to close any gaps in information about the patient. The exchange could lead to new insights about the patient’s condition as a result of both providers sharing perspectives with each other. Additionally, a handoff could even reveal a previously undetected error in the patient’s care, enabling the providers to intervene to stop the error from harming the patient.

A consistent format for shift-to-shift and unit-to-unit handoff reports helps staff members accurately record and recall information. One such tool is the SBAR technique to standardize communication. SBAR is a briefing technique that can be used by all professionals on the healthcare team. The managed care organization Kaiser Permanente developed the SBAR tool for briefings between nurses and physicians in the labor and delivery unit and expanded its application to enhance handoff communication between shifts, during patient handoffs between departments, and at other high-risk times to relay important information, communicate the plan of care, and prevent surprises (Denham; Leonard et al.). Following the SBAR acronym, the caregiver conducts the handoff by addressing the following:

  • Situation—define what is going on with the patient
  • Background—keep information brief, relevant, and on-point
  • Assessment—summarize what the caregiver found
  • Recommendation—describe what the caregiver should do

An SBAR Poster and Pocket Cards for staff are available for reprinting.

Another mnemonic tool to structure handoffs is called I PASS the BATON. The I PASS the BATON handoff tool was developed by the U.S. Department of Defense (DoD) Patient Safety Program for the transfer of patient information, as well as responsibility and accountability for patient care. The tool prompts the following exchange of information (AHRQ “TeamSTEPPS”):

  • Introduction—introduce caregiver and that individual’s role
  • Patient—provide patient’s name, other identifiers, age, sex, and location
  • Assessment—present chief complaint, vital signs, symptoms, and diagnosis
  • Situation—describe current status, circumstances, code status, recent changes, and response to treatment
  • Safety concerns—identify critical lab values, socioeconomic factors, allergies, and alerts such as falls risk and isolation precautions
  • Background—describe comorbidities, current medications, previous episodes, and family history
  • Actions—identify actions taken or required and provide brief rationale
  • Timing—address level of urgency, timing, and prioritization of actions
  • Ownership—identify care team responsible for patient and patient/family responsibilities
  • Next—discuss plan for patient, what will happen next, anticipated changes, and contingency plans

A third handoff mnemonic, I-PASS, was developed by a children’s hospital to standardize communication during hospital shift changes (Starmer et al.). It focuses on key information: Illness severity; Patient summary; Action list for the next team; Situation awareness and contingency plans; and Synthesis and “read-back” of the information.

Refer to Resource List for information on accessing these handoff tools online. Kaiser Permanente’s SBAR toolkit is available for download from the Institute for Healthcare Improvement’s website. The I PASS the BATON handoff tool is described in the TeamSTEPPS course on teamwork and communication developed by AHRQ and DoD. I-PASS materials available online include a staff education module on communication and the I-PASS handoff tool. Additionally, the Association of periOperative Registered Nurses provides a web-based toolkit to standardize handoff communication, which includes several sample handoff tools.

In addition to the handoff tools that rely on mnemonics, organizations have developed other standardized handoff processes. The Emergency Medicine Patient Safety Foundation has developed the Safer Sign Out form and protocol to improve the safety and reliability of end-of-shift handoffs. Use of the protocol could have helped to prevent the ED event described earlier resulting in the failure to communicate critical test results. Refer to Resource List for information on accessing the form and protocol online.

Handoff processes have also been incorporated into patient transport using what are often called “ticket to ride” forms. The forms are used to communicate essential information about a patient being transported from one unit to another. Information includes whether a patient is at risk of falling, pertinent medical information (e.g., code status, oxygen needs), communication issues (e.g., hearing impairment, language needs), and isolation precautions (West).

For any handoff to be effective, it must allow for an interactive exchange between the giver and receiver of patient information in a place free of distractions and interruptions. See Strategies for Effective Handoffs for recommendations to improve handoff communication.

Verbal Orders

Action Recommendation: Limit verbal orders to avoid errors; when verbal orders are unavoidable, require specific practices to minimize mistakes

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 clinical and nonclinical equipment operating, and the noise of pages, telephones ringing, and alarms sounding. All 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 and CMS CoPs. When it is highly impractical or impossible for the prescriber to write down orders or enter orders into a CPOE system at the time they are given, verbal or telephone orders may be the only available alternative. The receiver of the order is expected to write down the verbal or telephone orders as they are given and to read back the information as it is written for confirmation (Joint Commission Comprehensive).

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. In the case of electronic records, a keystroke or additional screen notation can be used. It is important that compliance with the read-back process be monitored through observation and/or record audits. In accordance with hospital policy and state and federal regulations, the ordering practitioner must promptly verify, sign, date, and time the order (42 CFR § 482.24[c][2]).

Based on reports of misheard drug names and errors involving other orders, as well as information in the literature on errors stemming from incorrect verbal and telephone orders, the Pennsylvania Patient Safety Authority, an independent state agency charged with analyzing reports of events and near misses from healthcare facilities in the state, has identified recommended practices for verbal orders. Refer to Safe Practices for Verbal Orders for the recommendations. Additionally, the Authority developed a verbal orders toolkit to assist facilities in assessing practices involving verbal orders, developing policies and procedures, and educating frontline staff on safe practices related to verbal orders. Refer to Resource List for information on accessing the toolkit online.

Test Results Reporting

Action Recommendation: Adopt standard practices for reporting critical test results and values

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 critical test results and values within the healthcare facility. Delays, failures, and inaccuracies in reporting test results place patients at risk for treatment delays, omissions, and errors. Cases involving failure in the timely reporting of critical lab results are a frequent source of lawsuits filed against hospitals, laboratories, and physicians (Dighe et al.).

To address the communication breakdowns that can occur with test results reporting, the Joint Commission established an NPSG to improve the effectiveness of communication among caregivers that requires accredited organizations to report critical results of tests and diagnostic procedures on a timely basis (Joint Commission “Hospital”).

The Joint Commission distinguishes between critical tests and critical results. According to the Joint Commission, critical tests are tests that will always require rapid communication of the results, even if the results are normal. On the other hand, critical results (also known as critical values) are test results that fall significantly outside the normal range and may represent life-threatening values, even if they are from routine tests. (Joint Commission “Hospital”)

In order to improve the timeliness of reporting, each diagnostic and clinical area in the facility, in conjunction with the physicians who provide care in each area, should first identify which tests and results are critical. One definition of “critical” that has been used is any test or test result that would immediately change the course of care. Specific tests and results are defined by each facility; designation of a test as critical usually involves some consideration of the associated clinical condition. An example of a critical test could be a computed tomography head scan to rule out subdural hematoma following head trauma. Conversely, while an electrocardiogram (ECG) in itself may not be a critical test, an ECG result that reveals a cardiac arrhythmia requiring immediate intervention would be a critical result. Some facilities allow the physician to specify that a test is critical when ordering it (Spath).

The Joint Commission expects facilities to develop procedures to standardize critical results reporting that address the following (Joint Commission “Hospital”):

  • Definitions for critical results of tests and diagnostic procedures
  • Method for reporting results—by whom and to whom
  • Acceptable time frame between the availability and reporting of critical results

The procedures should address measures for reporting results to a backup healthcare provider if the ordering clinician is unavailable. Additionally, the procedures should incorporate read-back practices if the results are reported verbally (refer to the discussion Verbal Orders for information on read-back methods) (“Safe Patient”).

Risk managers should ensure that test turnaround times are periodically monitored and evaluated, investigate instances in which results are not properly communicated, and implement improvements when needed.

A comprehensive toolkit for communicating critical results is available online from the Massachusetts Coalition for the Prevention of Medical Errors. Refer to Resource List for more information. Additional information on test results reporting in physician practices is available in the Guidance Article Test Tracking and Follow-Up.


Action Recommendation: Support team-based appoaches to care to enhance communication among team members

Traditional hospital hierarchies that place frontline caregivers 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 as a team. Studies have demonstrated that a team-based approach to care delivery can enhance communication and improve patient outcomes.

A study published in 2011 reported that facilities participating in a Veterans Health Administration (VHA) medical team training program experienced a 17% decrease in surgical morbidity rates (Young-Xu et al.). The retrospective study, which included 42 VHA facilities that implemented the program and 32 facilities that did not, analyzed data from 119,383 total surgical procedures. While the risk of surgical complications declined in both groups, the decline was 50% greater in the group that received the medical team training. The researchers conclude that participation in the VHA medical team training program, which emphasizes communication and teamwork during an operation through checklist-driven briefings and debriefings, is associated with lower surgical morbidity.

Healthcare facilities are providing team-building skills to break down hierarchies and foster good communication skills. Drawing on the experience of other complex, high-risk industries, healthcare facilities have turned to the aviation industry to support team building and communication with an approach called crew resource management (CRM). In aviation, CRM is used to train flight crews in critical communication, stress management, and team building.

A Pennsylvania hospital, for example, sought to improve patient safety in its ORs by implementing a CRM training program (McKoin et al.). The training program was designed to reduce the incidence of adverse surgical outcomes, including wrong-site surgeries and retained foreign objects, by creating an environment that encourages everyone to speak up if they feel that patient safety needs to be addressed. To do so, the OR teams adopted the following principles:

  • Conducting a presurgery briefing to introduce all team members. It has been shown that people who know each other by their first names are more likely to speak up if they see a problem.
  • Using the briefing to review the upcoming procedure (identification of the patient; confirmation of the procedure to be performed, as well as site, side, or level; and summation of the patient’s medical history) and to alert team members to potential problems and key portions of the procedure.
  • Conducting a debriefing after the procedure to review what went well and what could have been done better.

In addition to team briefings, debriefings, and empowering staff to speak up when a problem is detected, other elements of CRM include the following:

  • Situation monitoring to develop common understandings of the team environment and implement strategies to accurately monitor teammate performance
  • Conflict management (e.g., focusing on what is right, not who is right; developing an agreed-upon protocol for discussing and resolving disagreements in the moment)
  • Standardized communication, using techniques such as SBAR to convey information and confirmation feedback to validate the accuracy of a communication

AHRQ and DoD 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. Rooted in more than 20 years of research and lessons from the application of teamwork principles, the program is available online as a multimedia educational tool for healthcare providers and organizations. The TeamSTEPPS toolkit includes materials for classroom teaching, slide presentations, videos, case studies, and coaching exercises for interdisciplinary team training to help reduce the incidence of medical errors. The video vignettes depict staff interaction situations and patient care examples to help learners identify opportunities for more effective communication and enhanced teamwork to improve patient outcomes. Refer to Resource List for information on accessing the toolkit online.

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 for the patient, conflicts can still arise. Because of this, it is important to provide specific guidance on the most direct means of communication in making decisions regarding patient care. Healthcare facilities should have chain-of-command policies in place giving providers and staff clear lines of authority and paths of communication to follow for situations that may place patients at risk. For more information, see the Guidance Article Chain of Command.

Disruptive Behavior

Behaviors that intimidate or belittle staff members and hinder open communication are counterproductive to a team environment and a culture of safety. Healthcare organizations must strive to prevent or correct intimidating or disrespectful behaviors of physicians or others because these behaviors have a negative effect on the communication and collaboration necessary for safe patient care. The use of communication tools, such as briefings, checklists, and structured handoffs, will be much less effective if staff are reluctant to speak up because they are threatened by intimidating behavior. The Joint Commission has drawn attention to the issue with a Sentinel Event Alert (Joint Commission “Behaviors”) and accreditation standards that require healthcare organizations to address disruptive behavior. For more information, see the Guidance Article Disruptive Practitioner Behavior.


Action Recommendation: Minimize interruptions and distractions when information is being exchanged

Interruptions and distractions occur frequently in healthcare institutions, and the effects of interruptions can be detrimental to effective communication. During handoffs, for example, when information about a patient is transferred from one provider to another, caregivers should limit interruptions to focus on the information being exchanged.

Providing a well-lit and quiet place for a handoff exchange will help to minimize distractions and ensure an effective exchange. 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 know that during the handoff, they must focus their attention on exchanging essential patient information and limit interruptions (Mistry et al.).

High noise levels in busy areas, such as the OR and ED, can impair staff communication and negatively affect patient safety (Hasfeldt et al.; Welch et al.). Risk managers should work with their organizations to identify and implement strategies to reduce noise in these busy environments. One successful intervention described in studies is a behavior modification program that includes education for all staff who work in noisy areas such as the OR, a group discussion about excessive noise and its impact on patients and the work environment, and identification of modifications in the work environment that can reduce noise levels. Another hospital successfully reduced noise levels by monitoring the OR environment to identify common noise sources and developing clinical guidelines to guide staff behavior. (Hasfeldt et al.)

Even handheld devices intended to promote communication can be a source of distraction. One recent study found that healthcare providers who use smartphones during attending rounds can become seriously distracted during moments of important information transfer and thus cause risk of patient harm (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 to eliminate distractions from smartphone use that can negatively affect patient care delivery. The success of such policies will depend on support from key leadership and cooperation from mobile device users, including clinical and nonclinical staff, independent physicians, patients, and visitors. For more information on developing smartphone use policies, refer to the April 2013 Risk Management Reporter article Judgment Call: Smartphone Use in Hospitals Requires Smart Policies.

Technology Solutions

Action Recommendation: Support technologies that can transmit information across settings and between providers, but ensure they are planned and implemented carefully

When used properly, technologies that transmit information across settings and between care providers bring consistency and coordination to care practices and promote communication among providers. Electronic health records can provide caregivers with consistent, accessible patient information on such issues as whether a newly ordered medication was administered, whether lab tests were done, or whether a do-not-resuscitate order is in place. Additionally, health information technology (IT), such as CPOE systems, can reduce miscommunication involving handwritten medical orders such as medication orders, orders for laboratory tests, and treatment orders.

If not planned and implemented carefully, however, health IT can jeopardize effective communication and patient safety. For example, ECRI Institute has identified data entry errors in the wrong patient record as among the most frequent type of error associated with health IT (ECRI Institute PSO). While these errors are sometimes the result of human factors—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. 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 electronic health record).

Risk managers must remain alert to the possibility that health IT could be a contributing factor to adverse events, such as those involving communication errors. For instance, a medication administration error resulting in a missed dose could be the result of a faulty interface between two health IT systems, as in the following report to the Pennsylvania Patient Safety Authority (Sparnon and Marella): “A pharmacist entered correct day start time (9/10) for Lovenox®, but interface between pharmacy system and Bridge [administration system] caused the order to default to next day start time. The nurse signed off order without confirming correct order entry and did not ‘Add Dose’ in Bridge to correct start time; patient missed one dose.”

For more guidance on the risk manager’s role in ensuring the successful implementation of health IT systems, refer to the June 2013 Risk Management Reporter article Risk Managers’ 10 Strategies for Health IT Success.

Patient Engagement

Action Recommendation: Engage patients in their care while following strategies to ensure they understand the information provided to them.

An event, described in AHRQ’s online case study review, WebM&M, illustrates how poor communication between a patient and provider, compounded by language differences, can place the patient at increased risk for adverse events (Engel).

The event occurred when a woman with a torn anterior cruciate ligament (ACL) underwent surgery to repair it. During the procedure, the surgeon determined that her ACL was only partially torn, so instead of an ACL repair, the surgeon performed microfracture to address damage to the intraarticular cartilage and repaired her meniscus. After the procedure, the surgeon attempted to verbally communicate the necessary change in discharge instructions, which involved the leg being completely non-weight-bearing as opposed to 50% weight-bearing, but the woman was too groggy from anesthesia to understand. The surgeon called the number in her chart and left the revised instructions with the patient’s mother-in-law, but due to limited health literacy, she failed to understand the changes. After discharge, the patient mistakenly followed the original postprocedure instructions because they were not amended in writing, possibly harming her chances for a full recovery.

Communication breakdowns, possibly leading to patient harm, can occur if healthcare providers fail to engage their patients and to adopt measures to ensure they are understood by their patients. Refer to 10 Tips for Communicating with Patients for a list of suggestions. Additional information is available in the Guidance Articles Culturally and Linguistically Competent Care, Discharge Planning, and Health Literacy. Additional tools to promote effective communication with patients—Health Literacy: Checklist for Creating or Evaluating Materials and Health Literacy: Handout for In-Person Communication—are available as well.

Careful consideration must be given to communicating an unanticipated outcome to a patient and the patient’s family members. The topic is discussed in depth in the Guidance Article Disclosure of Unanticipated Outcomes.

Education and Training

Action Recommendation: Provide education and training on effective communication for physicians and staff members involved in patient care

Risk managers are uniquely positioned to promote communication improvement efforts in their facilities. Physicians and other staff members involved in patient care should be provided with opportunities to enhance communication skills formally through completion of education and training programs and informally through peer evaluations.

The content for an education and training program on communication is highlighted in Learning Objectives for Staff Training in Communication. Risk managers should ensure that the training program provides adult learners with opportunities for active participation through role-playing, simulation, and discussion of effective and ineffective communication techniques. Case studies, like the examples in this Guidance article, can be used to stimulate discussion about communication breakdowns. Several case studies, as well as questions to provoke discussion, are featured in Communication and Disclosure Training Program.




42 CFR § 482.23(c)(3)(i) (2012).

42 CFR § 482.24(c)(2) (2012).

42 CFR § 482.25 (2012).

42 CFR § 482.54(a) (2012).

42 CFR § 482.55(a) (2012).

Agency for Healthcare Research and Quality (AHRQ):

Chart 5-1. Composite-level average percent positive response, across all 2012 database hospitals. In: Hospital survey on patient safety culture: 2012 user comparative database report [online]. 2012 Dec [cited 2013 Aug 5]. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2012/hosp12chart5-1.html

Hospital survey on patient safety [online]. 2013 Jul [cited 2013 Aug 8]. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf

TeamSTEPPS fundamentals course: module 6: communication: classroom slides [online]. 2008 Nov [cited 2013 Aug 9]. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module6/slcommunication.html

AIG. Patient safety; hospital risk: perspectives of hospital c-suite and risk managers [online]. 2013 Apr [cited 2013 Aug 5]. http://www.aig.com/Chartis/internet/US/en/Patient Safety Hospital Risk White Paper_tcm3171-482027.pdf

American College of Obstetricians and Gynecologists (ACOG). ACOG committee opinion no. 517: communication strategies for patient handoffs. Obstet Gynecol 2012 Feb;119(2 Pt 1):408-11. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22270316

American Hospital Association. Hospitals and care systems of the future [online]. 2011 Sep [cited 2013 Sep 3]. http://www.aha.org/content/11/hospitals-care-systems-of-future.pdf

Beach C. Lost in transition [online]. WebM&M 2006 Feb [cited 2013 Aug 5]. http://www.webmm.ahrq.gov/cases.aspx

Centers for Medicare and Medicaid Services (CMS). State operations manual. Appendix A—survey protocol, regulations, and interpretive guidelines for hospitals. Tag A-0407 [online]. 2013 Jun 7 [cited 2013 Aug 7]. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

Chapman KB. Improving communication among nurses, patients, and physicians. Am J Nurs 2009 Nov:109(11 Suppl):21-5. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/19826329

Cvetic E. Communication in the perioperative setting. AORN J 2011 Sep;94(3):261-70. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21884846

Denham CR. SBAR for patients. J Patient Saf 2008 Mar;4(1): 38-48.

Dighe AS, Makar RS, Lewandrowski KB. Medicolegal liability in laboratory medicine. Semin Diagn Pathol 2007 May;24(2):98-107. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/17633351

ECRI Institute PSO. ECRI Institute PSO Deep Dive: health information technology. Plymouth Meeting (PA): ECRI Institute PSO; 2013.

Engel K. Discharge instructions in the PACU: who remembers? [online]. WebM&M 2013 Jul-Aug [cited 2013 Aug 13]. http://webmm.ahrq.gov/cases.aspx

Fink AS, Prochazka AV, Henderson WG. Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial. Ann Surg 2010 Jul;252(1):27-36. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/20562609

Goldenhar LM, Brady PW, Sutcliffe KW, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf 2013 Jun 6 [epub ahead of print]. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/23744537

Hasfeldt D, Laerkner E, Birkelund R. Noise in the operating room—what do we know? A review of the literature. J Perianesth Nurs 2010 Dec;25(6):380-6. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21126668

Haynes AB, Weiser TG, Berry WR, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009 Jan 29;360(5):491-9. Also available at http://www.nejm.org/doi/full/10.1056/NEJMsa0810119 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/19144931

Hoffman J, Raman S. Communication factors in malpractice cases [online]. 2012 Mar 15 [cited 2013 Jul 31]. https://www.rmf.harvard.edu/Clinician-Resources/Article/2012/Insight-Communication-Factors-in-Mal-Cases

Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001.

Joint Commission:

Behaviors that undermine a culture of safety [online]. Sentinel Event Alert 2008 Jul 9 [cited 2013 Aug 12]. http://www.jointcommission.org/assets/1/18/SEA_40.PDF

Comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission Resources; 2013.

Hospital: 2013 National Patient Safety Goals (NPSGs) [online]. 2013 [cited 2013 Aug 7]. http://www.jointcommission.org/hap_2013_npsg

Sentinel event data: root causes by event type, 2004-2012 [online]. 2013 Feb 7 [cited 2013 Jul 31]. http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf

Katz-Sidlow RJ, Ludwig A, Miller S, et al. Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction. J Hosp Med 2012 Oct;7(8):595-9. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22744793

Kooienga S, Stewart VT. Putting a face on medical errors: a patient perspective. J Healthc Qual 2011 Jul-Aug;33(4):37-41. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21733023

Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004 Oct;13 Suppl 1:i85-90. Also available at http://qualitysafety.bmj.com/content/13/suppl_1/i85.long PubMed: http://www.ncbi.nlm.nih.gov/pubmed/15465961

Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008 Jan;143(1):12-7. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/18209148

McKoin S, Arbittier D, Wesner VS, et al. Building a culture of operating room safety using crew resource management. Pa Patient Saf Advis [online] 2010 Jun 16 [cited 2013 Aug 12]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/jun16_7(suppl2)/Pages/01.aspx

Mistry KP, Jaggers J, Lodge AJ, et al. Using Six Sigma methodology to improve handoff communication in high-risk patients [online]. [cited 2013 Aug 13]. http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-mistry_114.pdf

Safe patient outcomes occur with timely, standardized communication of critical values. Pa Patient Saf Advis [online] 2009 Sep [cited 2013 Aug 12]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Sep6(3)/Pages/93.aspx

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013 Mar 5;158(5 Pt 2):365-8. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/23460091

Shostek K, Webster J. Briefs and debriefs: improving communication, reducing errors, and enhancing safety [online]. Prof Liabil Risk Resour 2013 [cited 2013 Sep 3]. https://www.sedgwick.com/news/Risk Resources/Sedgwick_PL_Newsletter-final(2013-2ndEd).pdf

Sparnon E, Marella WM. The role of the electronic health record in patient safety events. Pa Patient Saf Advis [online] 2012 Dec [cited 2013 Aug 13]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Dec;9(4)/Pages/113.aspx

Spath P. Don't fail to communicate critical test results. Hosp Peer Rev 2008 Apr;33(4):58-60. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/18689086

Starmer AJ, Spector ND, Srivastava R, et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics 2012 Feb; 129(2):201-4. Also available at http://pediatrics.aappublications.org/content/129/2/201.full.pdf PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22232313

Vidyarthi AP. Triple handoff [online]. WebM&M 2006 Sep [cited 2013 Aug 9]. http://www.webmm.ahrq.gov/case.aspx?

Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf 2013 Jun;39(6):279-86. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/23789167

West J. "Ticket to ride": how useful is this new handoff tool. J Healthc Risk Manag 2009;29(1):28-33. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/19774970

Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg 2011 Dec;146(12):1368-73. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22184295

Resource List

Agency for Healthcare Research and Quality
(301) 427-1364

American Congress of Obstetricians and Gynecologists
(800) 673-8444

Association of periOperative Registered Nurses
(800) 755-2676

Emergency Medicine Patient Safety Foundation
(916) 357-6723

Institute for Healthcare Improvement
(866) 787-0831

I-PASS Study Group/Boston Children's Hospital

Joint Commission
(630) 792-5800

Massachusetts Coalition for the Prevention of Medical Errors
(781) 262-6081

Pennsylvania Patient Safety Authority
(717) 346-0469

World Health Organization
41 (22) 791 21 11

Additional Materials

Table. Structured Communication Tools

Tool Example
Briefings and debriefingsA morning briefing tool promotes effective communication between two or more people, such as a night nurse and an incoming physician, before patient rounds in an inpatient unit.
ChecklistsA surgical safety checklist reminds team members to address basic but critical steps at three points: before anesthesia, before the surgeon makes an incision, and before the patient leaves the OR.
HandoffsPatient-specific information is conveyed from one caregiver to another or from one level of care to another. Healthcare staff use the SBAR (i.e., situation, background, assessment, recommendation) technique to standardize what information is communicated.
HuddlesA 5- to 10-minute huddle gives an opportunity for providers and staff to communicate new critical patient information or discuss and plan how to handle an emerging or changing situation on the care unit.
Repeat back and
teach back
A unit nurse repeats back instructions from a patient's physician to verify understanding, clarify as needed, and review the important information one more time; a patient demonstrates his or her understanding of how to use a device to manage his or her care.


Handoff Essentials

The following information should be included in a handoff exchange when a patient's care is transferred from one provider or care unit to another (several mnemonic devices, discussed elsewhere in this Guidance article, are available to aid in the exchange of this information):

  • 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 history, active medications, and allergies
  • Recent and pending laboratory tests
  • Immediate patient care concerns (i.e., during the next 18 to 24 hours)
  • Recommendations

Sources: Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005 Dec;80(12):1094-9. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/16306279; What does JCAHO expect for handoffs? OR Manager 2006 Apr;22(4):11. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/16683479

Strategies for Effective Handoffs

  • Allow enough time for the handoff exchange.
  • Limit distractions and interruptions as much as possible.
  • Use clear language and be concise.
  • Limit the exchange of information to that which is necessary to provide safe patient care.
  • Have information readily available.
  • Allow for interactive communication in which the receiver of patient information has time to review it and in which the giver and receiver of patient information each have an opportunity to ask questions of the other.
  • Require a repeat-back process for verification of received information.
  • Require a transfer of responsibility for the patient, in addition to the transfer of information, as part of the handoff.
  • Educate staff on how to use the handoff tool.

Sources: Apker J, Mallak LA, Applegate, EB, et al. Exploring emergency physician-hospitalist handoff interactions: development of the handoff communication assessment. Ann Emerg Med 2010 Feb;55(2):161-70. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/19944486; Collaborating Centre for Patient Safety Solutions. World Health Organization. Communication during hand-overs [online]. 2007 May [cited 2013 Aug 9]. http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf 

Safe Practices for Verbal Orders

The following safe practices, although not feasible in all facilities, can help facilities evaluate current practices regarding verbal orders:

  • Require that the verbal order be clearly communicated. For example, the name of a drug can be spelled out; use "d as in 'David,'" "b as in 'bravo,'" and so forth.
  • Provide brand and generic names of a medication, and include the purpose of the drug in the order.
  • Avoid confusion with spoken numbers by pronouncing digits separately (e.g., 50 mg should be enunciated as "fifty milligrams, five-zero milligrams" to avoid confusion with 15 mg).
  • Include the mg/kg dose along with the patient-specific dose for all verbal neonatal and pediatric medication orders.
  • Have a second person listen to the verbal order whenever possible.
  • Record the verbal order directly onto an order sheet in the patient's chart. Do not transcribe it from a scrap of paper.
  • Make sure that the verbal order includes the patient's name, age, and weight; the drug name; the dosage form; the exact strength or concentration; the dose, frequency, and route; the quantity and/or duration of medication; the purpose or indication; specific instructions for use; the prescriber's name and telephone number, when appropriate; and the name of the individual transmitting the order (if that individual is different from the prescriber).
  • Require the receiver to provide the date and time and his or her signature with the order and to document it according to procedure.
  • Limit the number of personnel who may receive telephone orders.
  • Limit verbal orders to orders for formulary drugs.
  • Whenever possible, have a pharmacist receive verbal orders for medications.

Source: Improving the safety of telephone or verbal orders. PA PSRS Patient Saf Advis [online] 2006 Jun [cited 2013 Aug 12]. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Jun3(2)/Pages/01b.aspx

10 Tips for Communicating with Patients

  1. Ensure communication with patients is at or below a sixth-grade reading level.
  2. Limit the complexity and quantity of information provided.
  3. Avoid medical jargon when it is not necessary; use terms like "earache" and "heart attack" instead of "otitis media" and "myocardial infarction."
  4. Repeat and reinforce key information to provide patients the opportunity to receive and retain their instructions.
  5. Ask patients to repeat back instructions in their own words to verify their comprehension and clarify any misunderstandings.
  6. Provide reading material that is printed in a font size and typeface that can be read by the patient, particularly seniors who may have difficulty reading small text.
  7. Demonstrate cultural awareness and sensitivity to the patient's preferences.
  8. Provide information in the patient's language.
  9. Speak slowly and clearly with the patient, and allow time for the patient to ask questions.
  10. Initiate follow-up contact with patients after hospital discharge to give the patient an opportunity to clarify instructions and to ensure posthospital care coordination.

Sources: Engel K. Discharge instructions in the PACU: who remembers? [online]. WebM&M 2013 Jul-Aug [cited 2013 Aug 13]. http://webmm.ahrq.gov/cases.aspx; 10 common errors healthcare professionals make communicating with patients [online]. Nurse Educ Nov-Dec 2008 [cited 2013 Aug 13]. http://journals.lww.com/nurseeducatoronline/Fulltext/2008/11000/10_Common_Errors_Healthcare_Professionals_Make.6.aspx

Learning Objectives for Staff Training in Communication

  • Describe the importance of communication in the provision of safe, quality medical care
  • Recognize the connection between communication and medical error
  • Discuss regulatory and accrediting agencies' initiatives to promote effective communication
  • Define effective communication
  • Identify barriers to effective communication
  • Describe strategies for information exchange (e.g., handoffs, repeat back, briefings)

Time should also be set aside for staff to demonstrate their understanding of and familiarity with the communication strategies and tools covered during the training session.

Source: Agency for Healthcare Research and Quality. TeamSTEPPS fundamentals course: module 6: communication: classroom slides [online]. 2008 Nov [cited 2013 Aug 9]. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module6/slcommunication.html

Related Resources

Topics and Metadata


Culture of Safety; Health Information Technology; Incident Reporting and Management; Medication/Drug Safety; Interprofessional Communication


Hospital Inpatient

Clinical Specialty



Allied Health Personnel; Behavioral Health Personnel; Clinical Laboratory Personnel; Clinical Practitioner; Dentist; Health Educator; Healthcare Executive; Insurer; Legal Affairs; Nurse; Patient/Caregiver; Patient Safety Officer; Pharmacist; Quality Assurance Manager; Regulator/Policy Maker; Risk Manager

Information Type


Phase of Diffusion


Technology Class


Clinical Category



SourceBase Supplier

Product Catalog








Publication History

​Published December 23, 2013