COMMUNICATION AS A ROOT CAUSE OF ADVERSE PATIENT EVENTS
In this blog, I’ll review the findings from the most recent Nurse Professional Liability Exposure Claim Report, as well as findings from the Joint Commission, specific to communication
as a root cause factor that contributes to adverse patient events. I’ll highlight barriers to effective communication, as well as risk mitigation strategies.
Communication Barriers: According to the Nurse Professional Liability Exposure Claim Report (2023), communication barriers can prevent or delay nurses from reporting changes in the patient’s condition, invoking the chain of command, clarifying orders, or raising
concerns about systems and processes.
Total Incurred: It has been reported that allegations specific to communication had an average total incurred of $324,260, which is more than one and a half times greater than the overall average total incurred for all nursing professional liability claims of $210,513 (Nurse Professional Liability Exposure Claim Report, 2023).
Risk Mitigation Strategies
Communication Techniques: The Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ) provides supportive education and training specific to effective communication. Specific techniques that promote effective communication across the multidisciplinary team includes, but is not limited to, the following:
TeamSTEPPS® program: Teaches healthcare teams effective strategies to improve communication across all specialties and promotes situational awareness. One of the several verbal strategies that are recommended includes:
- TeamSTEPPS® program: Teaches healthcare teams effective strategies to improve communication across all specialties and promotes situational awareness. One of the several verbal strategies that are recommended includes:
• SBAR: This acronym stands for Situation, Background, Assessment, and Recommendation/Request. SBAR is a communication technique intended to relay significant information regarding a patient’s condition or may be used during hand off report (AHRQ, 2013). - Check-back: Involves closed-loop communication to ensure that
information communicated by the sender is understood by the
receiver as intended by repeating back information. - Hand-offs: Require timely, complete and accurate transfer of information from one
caregiver to another (Joint Commission, 2018).
Nurses as Patient Advocates: Nurses have a duty and obligation to serve as patient advocates. This duty ensures that their patients receive safe and appropriate care. Nurses must be comfortable implementing the chain of command whenever they believe a practitioner is not responsive to calls for assistance, fails to appreciate the seriousness of a situation or neglects to initiate an appropriate intervention (Nurse Professional Liability Exposure Claim Report, 2023).
Enhancing knowledge of the root cause of adverse events, influences the power to reduce the risk of recurrence. Identifying the barriers to effective communication and mindfully applying communication techniques reduces adverse patient outcomes. Supporting a culture of safety within healthcare organizations supports open communication, promotes patient advocacy, shared accountability, and most importantly, patient safety.
References
Agency for Healthcare Research and Quality. TeamSTEPPS®, (2013). Retrieved from https://www.ahrq.gov/teamstepps/instructor/fundamentals/index.html
Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation, (2017). Retrieved from https://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx
Nurse Professional Liabiilty Exposure Claim Report, (2023). 4th Edition. Retrieved from www.nso.com/nurseclaimreport
The Joint Commission. 8 tips for high-quality hand-offs, (2018). Retrieved from
P.S. Comment and share: How did communication barriers impact a past, or current case? How were patient outcomes influenced?