Failures in Healthcare Developing Methods to Reduce CommunicationRelated Incidents Milisa Manojlovich PhD RN CCRN 1 Elizabeth Umberfield BSN RN 1 Amir Ghaferi MD MS 2 Sarah Krein PhD RN ID: 799273
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Identifying and Classifying Communication Failures in Healthcare: Developing Methods to Reduce Communication-Related Incidents
Milisa Manojlovich, PhD, RN, CCRN1Elizabeth Umberfield, BSN, RN1Amir Ghaferi, MD, MS2Sarah Krein, PhD, RN3,1,2
1
University of Michigan, School of Nursing;
2
University of Michigan, Medical School;
3
Department of Veterans Affairs, Center for Clinical Management Research
Slide2AcknowledgementRisk Management Department
Slide3BackgroundC
ommunication failures and patient safety“In the moment” vs. retrospective methodsCharacterizing and learning from failuresHospital incident reportsCan they
be used to identify failures?
Slide4Study PurposeTo
identify and characterize communication failures between nurses and physicians by applying a classification method to incident reports.
Slide5Study DesignQualitative descriptive design
Large Midwest tertiary care health systemElectronically captured incident reporting system (RL6: Risk)
Slide6Slide7Population Studied
Slide8Conceptual Framework: Rhetoric
Slide9Halverson et al. (2011) Classification
Failure Type
Definition
Error of Content
Information in the message was inaccurate, missing, or unclear
Error of Occasion
Something in the physical or temporal situation/context of the message was wrong
Error of Purpose
Unresolved goals (implicit or explicit) of the communication event
Error of Audience
Appropriate individuals were not participating
Error of Omission
Communication was absent
Error of Inappropriate Communication
Communication consisted of offensive remarks or unreasonable requests
Slide10Error of ContentDefinition
Information in the message was inaccurate, missing, or unclear.
Brief Example from Text
Nurse on unit was given report from OR on a patient arriving to the unit and was told that they were only on
propofol
and insulin.
Pt arrived with vasopressin, norepinephrine, and milrinone
in addition to the
propofol
, and insulin.
Slide11Error of Occasion: PhysicalDefinition
Something in the physical or
temporal
situation/context of the message was
wrong.
Brief Example from Text
Per night RN: the following morning orders were never entered. However, they were written at 2159 but
were signed and held (the night nurse didn't see them).
Slide12Error of Occasion: TemporalDefinition
Something in the physical or temporal situation/context of the message was
wrong.
Brief Example from Text
An insulin infusion’ initiated from instruction from endocrinology to nursing staff and patient without an actual order being placed in chart. Advanced practice provider attempted to get information from endocrinologist, but
due to delay in hearing back no order was placed until the following morning
from recommendations were documented the evening before.
Slide13Error of PurposeDefinition
There were unresolved goals (implicit or explicit) of the communication event.
Brief Example from Text
On multidisciplinary rounds I
(RN) brought up to attending and CCMU fellow that PICC could be a source of infection and that we should consider removing it.
MDs felt that it wasn't necessary given that pt. has VAE and blood cultures have been negative. I explained my rationale for concern given vital signs and +SIRS criteria.
At this time the line remains in place.
Slide14Error of AudienceDefinition
Appropriate individuals were not participating. Brief Example from Text
Mr.*** was put on call for the OR and brought to
preop
. Pt was in
preop
for 2
hrs
with family. I called the OR charge nurse to see what the delay was with
pt's
case. She stated she was just told that the
pt
was cancelled.
Apparently the service had decided earlier that am that they were not going to do the procedure. No communication with OR,
preop
or the
pt
that he was cancelled.
Pt and family were not happy with the situation.
Slide15Error of OmissionDefinition
Communication was absent.Brief Example from Text
Physician NOT notified of patient's T38 at 7pm. [MD] Tried to tell charge nurse, no answer. Paged nurse to notify physicians of abnormal vital signs, no response.
Slide16Error of Inappropriate CommunicationDefinition
Communication consisted of offensive remarks or unreasonable requests.Brief Example from Text
I inadvertently contaminated the corner of a sterile table. I immediately notified the scrub and told him that the towels were contaminated and his gloves and pen were too. He
shouted, "No they're not!" and threw the pen on the table and threw the towels on the floor
.
He changed his gloves but continued to use the pen. I asked him to stop,
but he shouted that he was done talking to me and said he was going to write this up as anesthesia is always contaminating tables and he has to "watch us like a hawk.”
Slide17Results
The 161 reports involved at least one communication failure.40 reports (~25%) contained more than 1 failure.In the 161 reports, there were 211 failures.
Errors of omission were the most common (
27%).
Of the
161 reports,120
named adverse outcomes:
Delays in care
(57%)
Actual or potential for physical harm
(30%)
Dissatisfaction
(13%)
Slide18Takeaways
Nonspecific communication interventions are unlikely to improve patient safety.We extend our knowledge of communication failures using retrospective data found in incident reports. While not generalizable, our method may represent a way to understand and act upon communication failure types within a specific healthcare setting.
Slide19Conclusions/ImplicationsOur adapted failure classification system represents an advance in identifying types of failures and contributing factors.
Incident report data could be used to make recommendations to reduce future failures.Using these methods, we can design and test interventions to improve communication.
Slide20Thank you!!
Questions? Comments?mmanojlo@umich.edu @
mmanojlo