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Identifying and Classifying Communication Identifying and Classifying Communication

Identifying and Classifying Communication - PowerPoint Presentation

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Identifying and Classifying Communication - PPT Presentation

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

error communication text failures communication error failures text reports message nurse incident failure patient physical situation context classification temporal

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Slide1

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

Slide2

AcknowledgementRisk Management Department

Slide3

BackgroundC

ommunication failures and patient safety“In the moment” vs. retrospective methodsCharacterizing and learning from failuresHospital incident reportsCan they

be used to identify failures?

Slide4

Study PurposeTo

identify and characterize communication failures between nurses and physicians by applying a classification method to incident reports.

Slide5

Study DesignQualitative descriptive design

Large Midwest tertiary care health systemElectronically captured incident reporting system (RL6: Risk)

Slide6

Slide7

Population Studied

Slide8

Conceptual Framework: Rhetoric

Slide9

Halverson 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

Slide10

Error 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.

Slide11

Error 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).

Slide12

Error 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.

Slide13

Error 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.

Slide14

Error 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.

Slide15

Error 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.

Slide16

Error 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.”

Slide17

Results

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%)

Slide18

Takeaways

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.

Slide19

Conclusions/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.

Slide20

Thank you!!

Questions? Comments?mmanojlo@umich.edu @

mmanojlo