Patient safety and human factors: human factors - communication

Definition: Communication is the transfer of information, ideas or feelings (Flin 2009, p.16).
 
Communication performs a number of functions in a heath care system. It:

(Flin 2009).
 
A standard model for communication has a sender converting an idea into a message using a medium of some sort (e.g. written record, phone conversation etc) with which to transmit a message to one or more receivers who then translate the message back to the original idea.

Communication failure can arise at any point in the sequence. These can be problems with transmission or reception.

Communication issues have been highlighted in all parts of the heathcare system and in the transitions between care settings (O'Daniel and Rosenstein 2008; Cohen 2010; Braaf 2011; Health Foundation 2011; Carroll 2012). Poor communication is one of the most common causes for disatisfaction with the NHS (Patient and Health Service Ombudsman 2011), and a growing body of research evidence shows the strong links between effective team communication and clinical outcomes (Alfredsdottir et al 2008). HealthGrades 2012 edition of America's Best Hospitals reports that those hospitals rated in the bottom 10 per cent for "nurse communication" reported 27 per cent more patient safety events than those in the top 10 per cent performing hospitals (HealthGrades 2012).
 
Much progress has been made on understanding the contribution of communication issues to adverse patient safety events. But there are aspects of communication that are underexplored such as the role of hierarchy or culture in inhibiting communication, the uptake of improvement initiatives or how communication systems can shape events that impact on patients downstream (Lingard 2012).

For ideas about how to reduce risks to do with communication go to our Action on communication page.

References

These resources were last accessed on 21 November 2012. Some of them are in PDF format - see how to access PDF files. 
 
Alfredsdottir H and Bjornsdottir K (2008) Nursing and patient safety in the operating room, Journal of Advanced Nursing, 61(1) January, pp.29-37.
 
Braaf S et al (2011) The role of documents and documentation in communication failure across the perioperative pathway. A literature review, International Journal of Nursing Studies, 48(8) August, pp.1024-38.
 
Carroll JS et al (2012) The ins and outs of change of shift handoffs between nurses: a communication challenge, BMJ Quality and Safety, 21(7) July, pp.586-593.

Cohen M and Hiligoss PB (2010) The published literature on handoffs in hospitals: deficiencies identified in an extensive review, Quality and Safety in Health Care,19(6) December, pp.493-497.

Flin R et al (2009) Human factors in patient safety: review of topic and tools. Report for Methods and Measures Working Group of WHO Patient Safety (PDF 424KB), Geneva: World Health Organization.

Health Foundation (2011) Evidence scan: Levels of harm in primary care, London: Health Foundation.
 
HealthGrades (2012) Good communication is at the heart of quality care, HealthGrades website. Based on HealthGrades (2012) Patient safety and satisfaction: The State of American Hospitals 20(PDF 918.36).   

Lindgard L (2012). Productive complications: emergent ideas in team communication and patient safety, Healthcare Quarterly, Vol 15 special issue April, pp.18-23.

O’Daniel M and Rosenstein A (2008) Professional communication and team collaboration. In Hughes RG (Ed) Patient safety and quality: an evidence-based handbook for nurses, Rockville, Maryland: Agency for Healthcare Quality and Research. Section V: Critical opportunities for patient safety and quality, Ch.33.

Parliamentary and Health Service Ombudsman (2011) Listening and learning: the Ombudsman's review of complaint handling by the NHS in England 2010-11, Parliamentary and Health Service Ombudsman website.