Communication breakdowns and their impact on patient safety

Teamwork within a clinical setting requires coordination, cooperation and communication between the healthcare staff to achieve desired patient outcomes and improved patient satisfaction. Communication is regarded of utmost importance for providing high quality patient care services. Breakdowns in communication have resulted in medication errors and other health problems that may contribute to health complications (Brock et al., 2013). Errors due to ineffective or miscommunication can also be fatal for a patient. Research evidences suggest that poor communication creates adverse impacts on hospital care. The most common type of provider-to-provider miscommunication includes, poor documentation, failure in interpreting the medical records of the patient and miscommunication about clinical status of a patient during handover (James, 2013).

On the other hand, provider-to-patient communication issues encompass, lack of clinical literacy, lack of informed consent, language and cultural barriers, lack of empathy towards patients and incomplete follow-up of instructions (Verlinde et al., 2012). Nursing leaders play a vital role in fostering verbal and nonverbal communication within the setting, which helps in establishing mutual understanding and in managing conflicts. One major tool that is implemented across clinical settings for fostering effective communication is the ISBAR (Identifying and Solving BARriers to Effective Handover in Inter-hospital Transfer). The primary purpose of this tool is to provide its users with the capacity to get adapted to the clinical setting, while implementing and evaluating clinical communication approaches during clinical handover in a healthcare organization (Kerr et al., 2014). This assignment will illustrate on the development of another strategy in a hospital setting to promote patient safety while improving communication among the employees. The aim of the essay is formulation, development and implementation of an effective communication tool, other than ISBAR that will enhance communication among the healthcare professionals in a ward, thereby improving patient safety.

Evidences from research states that documenting critical information regarding a patient and communicating them to the staff and the concerned family members helps in improving patient safety. One strategy that has been identified that can eliminate medication errors and can improve patient safety is the implementation of patient safety checklist and alerts. Documenting relevant patient information and alerts in these checklists improves patient outcomes (Van Klei et al., 2012). This view was supported by a systematic review that assessed the impact of surgical checklists on teamwork quality and communication in an operation setting. The review evaluated 20 articles that were based on considering safety checklists as a primary intervention for improving communication issues to maintain patient safety. The WHO Surgical Safety Checklist is designed in a way that encompasses three phases of sign-in, time-out and sign-out. 7 of the 20 articles reported in the study utilized the WHO safety checklist while, the other 13 were based on implementation of safety checklists that were in accordance with the national recommendations.

The role of patient safety checklists and alerts in improving patient outcomes

The results of the study showed that checklist implementation resulted in a significant reduction of miscommunication events. Furthermore, the review also reported that checklists helped in strengthening team feeling and a improved discussions of critical events, which in turn produced enhanced patient outcomes. Thus, the review was successful in providing evidence for the fact that checklists are increasingly gaining importance as an effective strategy for enhancing communication and improving patient safety. However, certain limitations were associated with the research methodology and quality of the study that were included (Russ et al., 2013). 

This view was further supported by another study that investigated the effect of the WHO surgical safety checklist on enhancing communication and reducing complications among patients (Fudickar et al., 2012). This study recognized that fact that poor teamwork and inadequate communication resulted in maximum errors in medication, which in turn contributed to violation of patient safety. It extensively searched for articles that contained information on the effectiveness of the proposed checklist and compared the outcomes on the perioperative morbidity, mortality and patient safety. The results were consistent with the previous findings and displayed an increase in patient safety. Furthermore, the study results demonstrated the beneficial effects of the checklist on correct guideline implementation and found a significant reduction in the complication rates among patients who underwent emergency surgeries. The study was also effective in providing evidences for an improvement in interdisciplinary communication and teamwork that directly influenced safety culture. The fact that a patient safety checklist contains relevant information on the patient history, prior medications, aspects of a surgery, its duration and the expected blood loss, was appropriately communicated between the concerned healthcare staff. Thus, effective communication through checklist implementation worked towards safeguarding the patients.

In addition, further support was provided by Böhmer et al., (2012) in a study that evaluated the quality of interprofessional communication and perioperative safety standards before and after the implementation of safety checklists. The study surveyed the attitude of employees related to safety aspects of patients in perioperative period and communication quality. The results were consistent with the previous findings and showed that positive effects were observed while verifying the written consent of patients, cognizance of names and quality of interprofessional cooperation after the checklists had been implemented.  Thus, the effectiveness of the checklists on significantly improving patient outcomes was again established.

The effectiveness of surgical safety checklists as communication strategies in safeguarding patient safety was also demonstrated by another study that utilized structured questionnaires to evaluate the outcomes on patient safety and communication, before and after the implementation of the checklists (Lepänluoma et al., 2014). The pilot study implemented surgical safety checklists across 4 Finnish hospitals and designed a multiple-choice questionnaire for anesthesiologists, surgeons, and nurses to evaluate the outcomes during a 6 week implementation period. An analysis of the responses to the questionnaires showed a reduction in the number of patient days and unplanned readmissions after the implementation of the communication strategy. There was a significant decrease observed in the number of patients with wound complications in neurosurgical cases. It was further proved by this study that surgical checklists helped in better transfer of information between the surgeons and anesthesiologists. This improved communication was responsible for enhancing safety related performance and reducing adverse events. Therefore, the study successfully provided evidence for the enhancement of awareness on safety issues related to patients among the healthcare professionals. It also helped in establishing the fact that implementation of surgical safety checklist played an essential role in preventing communication failures, thereby reducing patient complications and maintaining patient safety.

Evidence from studies supporting the effectiveness of surgical safety checklists

Pugel et al., (2015) further conducted a research that was in concordance with the previous findings.  The aim of the research was to investigate the use and effectiveness of surgical safety checklist for improving communication and reducing patient complications. It stated that patient safety is a major health concern among people, and gets violated most often due to communication lapses. Owing to the fact that the healthcare professionals are interdependent on each other, there is a need to communicate effectively in order to promote teamwork. It further showed that communication failures were a common phenomenon and affected patient safety. In addition, it provided evidence that suggested a decline by more than 50% in miscommunication events on surgical briefing. Furthermore, the results also suggested that checklists were essential for maintaining patient safety as they created provisions for the healthcare staff to voice their concerns for the respective patients, while sharing critical patient information. This helped in formulating a proper patient care plan and improving patient outcomes.

A team at the Broward Health Imperial Point Hospital, Ft Lauderdale, Florida tried to improve team communication by implementing a program that focused on the WHO proposed surgical safety checklist (Cabral et al., 2016). A safety attributes questionnaires was used as the measurement tool and helped to evaluate the attitudes of the caregivers on safety climate, perceptions, and team communication. Analysis of the responses using the SPSS 23 software package displayed highest internal consistency for communication among team members, which in turn improved the safety climate.  Maximum increase in communication was observed among nurses upon implementation of the tool. Thus, the checklist tool significantly affected the perceptions of the surgical team on communication. However, the major limitations were associated with the small sample size and anonymity of each sample. The fact that sharing critical information related to patient health via the implementation of surgical checklist fosters team communication and improves patient safety was again supported by another research. 

It suggested that communication errors contributed to adverse health outcomes among patients. Failure to make adequate information reach the correct persons often gave rise to critical issues. This resulted in mistakes in an operation theatre and also contributed to medication errors that violated patient safety. Evidence from this article indicated that sustained utilization of the WHO safety checklists helped in enhancing communication among healthcare staff and also ensured reliability of the interventions. Therefore, the research was successful in demonstrating the effectiveness of the communication tool for maintaining a safety culture within the health context. However, effective implementation of this communication strategy requires adequate coaching and training with regular feedback of outcomes (Tang, Ranmuthugala & Cunningham, 2014).

The importance of National Safety and Quality Health Service Standards in promoting effective communication in patient care

The Australian Commission on Safety and Quality in Health Care in collaboration with the states, territories and the government formulated a National Safety and Quality Health Service Standards (NSQHS, 2017) with the aim of safeguarding the public from adverse incidents and improving the quality of healthcare. Implementation of the standards ensures that the quality of health outcomes and patient safety are met. There are 8 NSQHS standards of which one focuses on communicating for enhancing safety. These standards are designed and maintained by the leaders of health service organizations to support effective communication between carers, patients and families (4.4 and 9.1). The standard also promotes sharing of information across the key stakeholders and implementation of an effective governance system to minimize patient risks (3.1). The standard encompasses 5 criteria that encompass proper identification and matching of procedures (5.1), communicating during clinical handovers (4.12; 6.1), quality improvement (2.2) and clinical governance (1.1) for supporting effective communication, communicating critical information and documenting information.

The communication tool identified above is consistent with the standard on documentation of information. The health service organizations utilize this safety checklist process to document information in the healthcare records. The information presented in the checklist contains critical information on the risks and alerts associated with particular patients. This checklist matches the criteria of the standard in that it strengthens the commitment shown by clinical staff while addressing safety of patients within surgical settings. Miscommunication often leads to errors in patient’s medication upon admission or during hospital stays. Such medication errors significantly contribute to death across healthcare settings. The safety checklists contain information on the confirmation of patient identity, marking of surgical site, complete check of medication and anesthesia machine, and previous history of allergy, blood loss or aspiration risks that need to be read out loud before inducing anesthesia (Bliss et al., 2012). The checklists also make it necessary to document information on the effectiveness of the team members of introducing themselves, verbal confirmation from the surgeons, anesthetists and registered practitioners, and anticipated critical events. Therefore, documenting all such critical information related to the role of healthcare professionals and the health status of the patients involved helps in enhancing communication between the staff, thereby improving patient safety (Aveling, McCulloch & Dixon-Woods, 2013). Thus, positive health outcomes are obtained, the rates of medication errors are reduced and the rates of mortality and morbidity are significantly lowered.

Nurses play a critical role in quality improvement. They are responsible for measuring, improving and controlling the factors that may affect patient outcomes. In addition, they are also involved in carrying out interdisciplinary processes that will help them meet the goals of the healthcare organizations. With the aim of quality improvement, the nurses participate in all aspects of patient care, medication management, surgery assistance, collection and reporting of data and sharing critical patient information with other team members. They are also imperative for educating the patients and their family members on the risk factors that may contribute to adverse health effects (Cullati et al., 2014). An ever increasing demand is observed for quality improvement across all hospitals due to the presence of hospital organizations, accreditation or regulatory boards, federal government mandates, medical societies, health insurance plans and non-profit organizations (NGOs). 

Therefore, the nurses must re-structure the hospital setting in order to undertake constructive actions that will help in safeguarding the patients. Clinical leadership qualities also make it mandatory for nurses to develop skills and knowledge that influence management changes (Tillman et al., 2013). They are expected to participate in the lead change management processes that will help them in identifying the gaps in the healthcare setting and devising strategies.

There are different barriers that may prevent the implementation of surgical safety checklists as effective communication strategy. Organizational barriers are associated to lack of training or education, no customization of practices according to patient demands, hospital culture, resistance to changes, and lack of support from hospital management (Hurtado et al., 2012). Checklist specific barriers include the structure or layout and content of the checklist, late time-outs, inappropriate documentation for surgical specialties and reaction of the concerned patients towards the checklists. Team barriers encompass noncompliance or resistance from senior nurses and surgeons for checklist implementation (Rydenfält et al., 2013). System barriers refer to the long time that is taken to document all information in the checklist and repetitions of existing safety practices.

There are certain facilitators for the implementation of this communication tool. Organizational facilitator focuses on creating provisions for education and training of the staff, conducting regular feedback sessions on the benefits of checklists, penalizing employees who exhibit noncompliance and gathering visible support from the management (Russ et al., 2015). Checklist specific facilitator encompasses modifying the communication tool to meet the healthcare context and making it more accessible and user-friendly. Team facilitator includes the strong leadership skills of the nurse who leads the implementation, visible leadership of senior clinicians, and customization of the checklist to suit all members of the multidisciplinary team (Bergs et al., 2015). On the other hand, system facilitator comprises of integration of the checklist documentation with existing paperwork to reduce workload and eliminate repetition of data. 

To conclude, the strategy that has been identified in the assignment is implementation of checklists that help nurses and other medical professionals to eliminate medication errors, thereby reducing patient harms. This strategy has positive implications in the healthcare settings because it can be utilized by nurses for checking presence of medical equipments, rechecking previous history of patients, and checking for the presence of effective interaction between the team members. The positive implications of these checklists include utilization of a formalized process that will help nurses to identify the gap related to lack of communication and adequate information. Thus, they will be able to improve information sharing process, which in turn will promote application of consistent procedures. These checklists will also bring about patient safety by providing the assurance that the medication processes are being followed thoroughly and accurately as a result of proper communication. This will also create an improved sense of confidence among the nurses and other staff.

Using the data present in the checklist will create provisions to minimize any form f distraction during medication administration and will build team spirit. Daily incorporation of the tool will prompt nurses to share information that they consider crucial for the survival of the patients, with the surgeons and anesthetists. Furthermore, it will also help nurses to report any risk factors and speak up when the patient safety will be found at stake. Therefore, documentation of relevant information in the safety checklists will act as a double-check communication strategy and will help in easy identification of errors. 

References

Aveling, E. L., McCulloch, P., & Dixon-Woods, M. (2013). A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ open, 3(8), e003039.

Bergs, J., Lambrechts, F., Simons, P., Vlayen, A., Marneffe, W., Hellings, J., … & Vandijck, D. (2015). Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. BMJ Qual Saf, bmjqs-2015.

Bliss, L. A., Ross-Richardson, C. B., Sanzari, L. J., Shapiro, D. S., Lukianoff, A. E., Bernstein, B. A., & Ellner, S. J. (2012). Thirty-day outcomes support implementation of a surgical safety checklist. Journal of the American College of Surgeons, 215(6), 766-776.

Böhmer, A. B., Wappler, F., Tinschmann, T., Kindermann, P., Rixen, D., Bellendir, M., … & Gerbershagen, M. U. (2012). The implementation of a perioperative checklist increases patients’ perioperative safety and staff satisfaction. Acta anaesthesiologica Scandinavica, 56(3), 332-338.

Brock, D., Abu-Rish, E., Chiu, C. R., Hammer, D., Wilson, S., Vorvick, L., … & Zierler, B. (2013). Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf, 22(5), 414-423.

Cabral, R. A., Eggenberger, T., Keller, K., Gallison, B. S., & Newman, D. (2016). Use of a Surgical Safety Checklist to Improve Team Communication. AORN journal, 104(3), 206-216.

Cullati, S., Licker, M. J., Francis, P., Degiorgi, A., Bezzola, P., Courvoisier, D. S., & Chopard, P. (2014). Implementation of the surgical safety checklist in Switzerland and perceptions of its benefits: cross-sectional survey. PLoS One, 9(7), e101915.

Fudickar, A., Hörle, K., Wiltfang, J., & Bein, B. (2012). The effect of the WHO Surgical Safety Checklist on complication rate and communication. Deutsches Ärzteblatt International, 109(42), 695.

Hurtado, J. J. D., Jiménez, X., Peñalonzo, M. A., Villatoro, C., de Izquierdo, S., & Cifuentes, M. (2012). Acceptance of the WHO Surgical Safety Checklist among surgical personnel in hospitals in Guatemala city. BMC health services research, 12(1), 169.

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety, 9(3), 122-128.

Kerr, D., McKay, K., Klim, S., Kelly, A. M., & McCann, T. (2014). Attitudes of emergency department patients about handover at the bedside. Journal of clinical nursing, 23(11-12), 1685-1693.

Lepänluoma, M., Takala, R., Kotkansalo, A., Rahi, M., & Ikonen, T. S. (2014). Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scandinavian Journal of Surgery, 103(1), 66-72.

NSQHS. (2017) (2nd ed.). Australian Commission on Safety and Quality in Health Care. Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2017/11/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Pugel, A. E., Simianu, V. V., Flum, D. R., & Dellinger, E. P. (2015). Use of the surgical safety checklist to improve communication and reduce complications. Journal of infection and public health, 8(3), 219-225.

Russ, S. J., Sevdalis, N., Moorthy, K., Mayer, E. K., Rout, S., Caris, J., … & Darzi, A. (2015). A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the “Surgical Checklist Implementation Project”. Annals of surgery, 261(1), 81-91.

Russ, S., Rout, S., Sevdalis, N., Moorthy, K., Darzi, A., & Vincent, C. (2013). Do safety checklists improve teamwork and communication in the operating room? A systematic review. Annals of surgery, 258(6), 856-871.

Rydenfält, C., Johansson, G., Odenrick, P., Åkerman, K., & Larsson, P. A. (2013). Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. International Journal for Quality in Health Care, 25(2), 182-187.

Tang, R., Ranmuthugala, G., & Cunningham, F. (2014). Surgical safety checklists: a review. ANZ journal of surgery, 84(3), 148-154.

Tillman, M., Wehbe-Janek, H., Hodges, B., Smythe, W. R., & Papaconstantinou, H. T. (2013). Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes?. journal of surgical research, 184(1), 150-156.

Van Klei, W. A., Hoff, R. G., Van Aarnhem, E. E. H. L., Simmermacher, R. K. J., Regli, L. P. E., Kappen, T. H., … & Peelen, L. M. (2012). Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Annals of surgery, 255(1), 44-49.

Verlinde, E., De Laender, N., De Maesschalck, S., Deveugele, M., & Willems, S. (2012). The social gradient in doctor-patient communication. International journal for equity in health, 11(1), 12.