Poor communication is common cause of errors

Communication critical, says JCAHO official

"If there were one aspect of health care delivery an organization could work on that would have the greatest impact on patient safety, it would be improving the effectiveness of communication on all levels — written, oral, electronic." With those words, Richard K. Croteau, MD, executive director for strategic initiatives for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), outlined an issue that he says is too often overlooked by quality professionals.

His comments were in reply to a query about a recent JCAHO Sentinel Event Alert, which, ironically, was not intended to address communication at all. In fact, it examined some of the key issues involved in delays in treatment.

The alert had several interesting findings. For example, of the 55 reported cases of delays in treatment, 29 were related to the emergency department (ED), meaning nearly half of the delays occurred outside the ED. The other 26 originated in hospital intensive care and medical-surgical units, inpatient psychiatric hospitals, freestanding and hospital-based ambulatory care services, the operating room, and the home care setting. Of the 55 delays, 52 resulted in patient deaths. Of the delays, 42% were attributed to misdiagnosis.

What JCAHO found perhaps most interesting was how participating organizations responded to these sentinel events. They suggested implementing multiple and varied strategies in responses, including redesign of:

  • orientation and training processes (80%);
  • transfer procedures (27%);
  • staffing plans (25%);
  • on-call specialist contact procedures (22%);
  • triage procedures (16%);
  • physical space (11%).

However, while analysis revealed that multiple root causes contributed to each sentinel event, most organizations (84%) cited a breakdown in communication as a major cause.

"While the organizations consistently identified communication, the risk-reduction strategies they said they were going to implement don’t directly address communication," Croteau notes. "We looked at what they said were the underlying causes of the sentinel events. What they do not address in their strategies is what they found as the cause."

Accordingly, JCAHO responded in the alert with its own additional recommendations for curtailing delays in treatment:

  • Implement processes and procedures designed to improve the timeliness, completeness, and accuracy of staff-to-staff communication, including communication with and between resident and attending physicians.
  • Implement face-to-face interdisciplinary change-of-shift debriefings.
  • Take steps to reduce reliance on verbal orders and require a procedure of "read-back" verification for when verbal orders are necessary.

The importance of these strategies takes on added significance because the communication problems are not limited to delays in treatment. "Breakdowns in communication are pervasive in all areas, and throughout all sentinel events," Croteau says. "When we look at all the sentinel events in our database (1,747 sentinel events) and at patterns of root causes, the most frequently identified cause is a breakdown in communication." Therefore, successfully addressing such breakdowns could make a big difference in minimizing sentinel events, he says.

The first step every organization should take is an analysis of the barriers to effective communications, Croteau advises.

"We have to think about how we communicate: orally, electronically, and in writing," he suggests. "In writing, potential barriers might be legibility of handwriting, incomplete orders, or abbreviations with multiple meanings. Electronic barriers might include faxes that are not very legible."

Croteau advises going through all your facility’s different forms, talking with staff, and finding out where they have trouble understanding what someone else is trying to tell them. "That’s a tremendous start; it tells you where the problems are," he observes.

This leads to JCAHO’s first recommendation on staff-to-staff communications. "Your specific strategies should be based on what is identified as a barrier. For example, docs have a habit of talking their orders. We encourage hospitals to limit verbal orders to those times when there are no options, like when there’s a code or when a surgeon is down and gloved," Croteau says.

"If you have to use verbal orders, the people who receive the order should write it down and read it back, and get confirmation they are right."

This is an important benchmark process, he points out. "Limit verbal orders, and have a strict read-back protocol," Croteau advises.

The second recommendation is based on the premise that when a new shift comes on, it must have the information it needs to provide continuity of care. "One barrier, we’ve been told, is that the different disciplines carry information that’s needed by other disciplines," he says.

"The process goes on, the patient needs care, but the players change. Continuity is critical; it is helpful to have a certain structure to the change-of-shift report," he says. "We advise against just tape-recording it, which has become a common nursing practice. There is no opportunity to seek clarification and ask questions; face-to-face dialogue is much more effective."

In most cases, Croteau recommends a systemwide approach to communication problems.

"My preference, as with most of these efforts, is that when the [outcomes] are systemwide, the solutions should be addressed systemwide. That does not mean certain strategies shouldn’t be pilot-tested departmentwide, but ultimately it should be done across the continuum of care," he adds.