The Quality-Cost Connection

Prevent communication breakdowns

Errors can occur during information transfer

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Patient safety can be jeopardized when the transitions or "handoffs" that occur during patient care are not managed effectively. Many errors come from slips that occur during the exchange of materials, people, and/or supplies.

Transfer of information — oral, written, or electronic exchanges — is critical. To minimize the risk of unintended patient harm, caregivers must ensure that information exchanges are timely, complete, and accurate. These exchanges can occur between caregivers within the same setting, between services or departments within the same setting, or between caregivers in different settings.

Each component within the patient care continuum must be adequately linked with every other component to enable unimpeded and timely flow of information. When information is effectively exchanged, quality of care is positively affected and there is less chance of an untoward outcome. Communication breakdowns can occur at any point within the continuum of care. When the information necessary for meeting a patient’s care needs is not effectively transferred, the patient can be exposed to unnecessary risk of harm. What might happen if the evening shift nurse in the hospital forgets to tell the night shift staff that a depressed patient has just started expressing suicidal ideation? Or suppose the radiology technician does not document that a patient has had a previous allergic reaction to contrast agents?

Continuity of patient information is essential to safe care. Clinicians must have knowledge of or ready access to relevant facts about a patient at all times. Complete and pertinent information must be available to all caregivers. Effective information sharing must occur among the practitioners caring for a patient, whether in the same institution, between institutions, or between care settings. Information continuity depends on data being up to date, accurate, retrievable, understood, and used. In transitions between settings of care, information is at risk of not being transferred, of being transferred but not read, of being read but misunderstood, or of being understood but discounted.

It is important to identify the barriers to effective communication during the process of patient care. (Click here to view the assessment tool) to examine the important information exchanges throughout the continuum of care. By evaluating the communication linkages, you’ll have a better understanding of the capability of your systems to support consistently safe, high-quality patient care. The statements shown in the tool are designed to stimulate your thinking about how information flows among caregivers, patients, and families. The assessment tool prompts you to identify less than optimal practices, those actions or activities that only occasionally or rarely occur. By completing the assessment, you should have a snapshot of the strengths and weakness of the information exchanges in your organization. This knowledge can be used to initiate appropriate improvement plans.

Once the barriers are recognized, steps can be taken to eliminate them. For example, misinterpretation on the part of the listener is a common barrier to successful oral communication. When oral communication is a vital component of the patient care experience (for example, exchange of verbal orders), a "repeat-back" system should be used to prevent miscommunications. Illegible handwriting is a common barrier to effective written communication. A computer-based ordering system removes the potential for errors caused by misread handwriting.

Caregivers should have ready access to critical information relative to patient care when it is needed. Techniques for ensuring ready access to information might include using color-coded wrist ID bands on patients with known drug allergies, or putting patient allergy information automatically on all medication order forms. A color-coded seat belt or flag attached to a wheelchair also can be used to denote patient status and supervision guidelines. This type of system communicates the patient’s status to all caregivers.

Ineffective transfer of information during patient care can create a dangerous situation that increases the risk of patient harm. For example, timely and reliable communication of critical abnormal test results to the clinician who needs to take action is important. Improving hospital communication procedures can make a significant contribution to patient safety.

A safety factor of particular concern is the role of interpersonal communications — between the clinician and patient, and between clinicians — in diagnosis and treatment. Previous studies have shown that communication failure is a contributor to adverse events. As patients become more diverse, their language and cultural differences will increase the likelihood of communication problems that result in errors or unintended injuries. It is important to understand that there are many contributors to an adverse event and that each must be addressed to provide patients with the utmost safety.

It’s time to begin analyzing one of the primary contributors, our information exchange processes, so that effective solutions can be found.