Communication and Patient Safety

September 1, 2013 | Ambulatory Care Risk, Quality, & Safety Guidance

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The importance of effective communication to improving patient safety in the physician office cannot be overestimated. Communication issues underlie many patient safety problems, and communication breakdowns are factors in most malpractice suits. Although there are many contributing factors to adverse events, the Joint Commission cites inadequate communication among providers or between providers and patients and their families as the root cause of all sentinel events (Joint Commission “Behaviors”). An interactive exchange of information is vital to the physician/patient relationship and establishes a basis for future positive encounters. Communication among providers regarding the patient’s condition, consultations, referrals, and follow-up is critical to coordination of the patient’s care.

This Guidance Article provides an overview of communication errors in the physician office, stresses the importance of effective communication among providers and during transitions of care such as patient handoffs, offers telephone communication tips, and introduces technology solutions for improving communication. For information on assessing communication and teamwork in the office, see the Guidance Article Patient Safety and Risk Management.

An analysis of errors reported by U.S. family physicians participating in the Primary Care International Study of Medical Errors (PCISME) sought to identify the chain of events that led to errors and the most prevalent underlying causes. In the analysis, researchers noted that the site of care implicated in 69% of the errors was the physician office. Eighty-three percent of all errors involved treatment or diagnosis mistakes; two-thirds were initiated by communication errors. Most errors involved some type of miscommunication, such as the following (Woolf et al.):

Even a simple error can have significant effects. For example, the PCISME analysis notes that in the case of a patient with hyperlipidemia, attaching the laboratory report of the wrong patient to a patient test result notification letter can lead to misdiagnosis of the patient's lipid status, miscommunication with the patient, and delay in treatment (Woolf et al.). The findings of this small but important study highlight the importance of effective communication with patients and among providers, including consultants, to ensuring safe, quality healthcare. Physicians and office staff should continuously seek to improve communication skills. An ECRI Institute training program, Communication and Disclosure, focuses on effective communication (as...

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