The value of effective communication during patient handovers
Just hours after being discharged from the emergency department, a five-week old infant sustained permanent brain damage due to a delayed diagnosis and treatment for meningitis. The cause – miscommunication and the absence of a reliable process to ensure pending tests following a patient discharge.
Cases like these beg the question, are poor communication practices during shift changes and transfers between care providers so ubiquitous in healthcare that we have become numb to their chilling effects on patient safety?
Sadly, we might think we’re communicating well but in the chaotic and stressful healthcare environment, the messages can easily start to look like a game of broken telephone.
Communication handovers – be they between healthcare providers, facilities or sectors – can be complex. One article suggested that the average healthcare provider encounters 11 to 15 interruptions hourly. Other research tells us that only 42% of nurses can identify their patient’s primary care provider and 23% of physicians can identify their patient’s primary nurse. According to CRICO, healthcare miscommunication cost $1.7B and impacted nearly 2,000 lives in a study of claims filed between 2009 and 2013.
A similar grim situation exists in Canada. The Canadian Adverse Events Study found miscommunication during care transitions were a key factor in medication adverse events. Based on claims data from HIROC (the Healthcare Insurance Reciprocal of Canada), communication failures contributed to an estimated $305 million in medical legal costs since 1987.
Contrary to these findings, The 2015 Accreditation Canada Report on Required Organizational Practices (ROP) revealed an overall compliance score of 99% for the practice of ensuring effective information at transition points. However, this finding specified that tests for compliance did not assess the quality of information transferred.
There are some promising signs that things are changing. We are seeing studies on standardized practices to bridge the gap between varying communication styles. There is also a focus on team-based safety practices such as routine huddles and debriefs to enhance communication. And finally, tools and resources like CPSI’s SHIFT to Safety platform help empower patients and families to start conversations during care transitions.
For leadership, it comes down to prioritizing effective communication, making use of technology and building of a culture of safety. We must do it for our staff, our organizations and for our patients who leave their fate in our hands.
By Joanna Noble, Supervisor, Knowledge Transfer Healthcare Risk Management, HIROC|