The Errors Of Communication Errors

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

“Errors in communication give rise to substantial clinical morbidity and mortality (Riesenberg, Leitzsch, & Cunningham, 2010).” As a result, the Joint Commission has identified effective communication as one of its National Patient Safety Goals (Dunsford, 2009).

Giving and receiving an incomplete or inadequate patient hand-off could mean the difference between life or death. In 2006, The Joint Commission addressed hand-off communication as a National Patient Safety Goal, and in 2010, the objective became a standard. However, evidence still shows there are gaps and that “substandard or variable hand-offs have contributed to errors, care omissions, treatment delays, inefficiencies from repeated work, inappropriate treatment, adverse events with minor or major harm, increased length of stay, avoidable readmissions, and increased costs” (Halm, 2013). The Joint Commission reported in 2017 that “ineffective hand-off communication was the cause of the majority of medical errors, including sentinel events” ("Inadequate Handoff Communication," 2017). The hospital I selected for my clinic hours uses a communication form that has not been updated in several years. These are the reasons why I chose to update and improve the current hand-off form for my sustainable product to promote better communication and increase patient safety. Furthermore, research proves that “successful hand-off improvement programs have the potential to substantially improve patient safety” ("Inadequate Handoff Communication," 2017).

A significant amount of communication is done between nurses at handoff report, and the patient’s safety can also be compromised at this time (Sand-Jecklin & Sherman, 2014). In a study conducted regarding near miss incidents, nurses reported that handoff report is a contributing factor (Sand-Jecklin & Sherman, 2014). Communication errors are the leading cause of patient harm and are the root cause of 65% of sentinel events (Tobiano, Chaboyer, & Mcmurray, 2013). If the bedside report is

Millions of Americans surrender to conditions that are both preventable and manageable annually. Besides chronic diseases, researchers have identified that the third leading cause of death in America is the errors conducted by professional medical practitioners. While medicine is a highly considered field, some of the practices that contribute to the errors observed include the absence of patient safety, poorly coordinated care, and inefficient healthcare quality improvement. Significant steps that can be taken to reduce deaths caused by medical errors include good communication, cooperation, use of advanced technology and implementation of quality healthcare among

The electronic handoff tool used in this study, eSignout, features automated communication and responsibility transfer with no mandatory verbal communication. The quality of communication and incidence of adverse or near-miss events were evaluated before and after the intervention. The results indicated similar quality of communication and adverse or near-miss events before and after intervention. However, it was reported that the intervention improved the quality of verbal communication when it occurred. In addition, participants perceived the eSignout as more efficient and preferred eSignout over verbal handoffs. An earlier study done by Li et al. cited below showed limited improvement of handoff quality when computerized physician handoff tools were used. Therefore, future studies are needed to explore the potential benefit of replacing face to face handoffs with other forms of handoffs, such as electronic or tele-communicative handoffs.

According to the Institute of Medicine (IOM) report, To Err Is Human, the majority of medical errors result from faulty systems and processes, not individuals (Hughes, 2008). However, due to processes that are inefficient and variable, multiple health insurance, differences in provider education and experience, and other factors that contribute to the complexity of health care the IOM has put together six aims of health care that is effective, safe, patient-centered, timely, efficient, and equitable (Hughes, 2008).

An observational study published in January of 2015 found several barriers to effective communication in handoff reporting. Two prominent barriers were identified; disorganization and the inability to understand the information received. The study determined by incorporating a structured tool for communication, which included categories, aided in ensuring the information’s completeness, as well as improved the level of understanding of the report content (Foster-Hunt, Parush, Ellis, Thomas, & Rashotte, 2015). Halm (2013), identified three key elements incorporated into an effective handoff report. These components included face-to-face or 2-way communication, a structured template or form, and content which allowed the health care worker to hypothesize a diagnosis related to the patients’ clinical condition (Halm, 2013). The four most frequent elements discussed in a handoff report were history, events, patient status, and future care plan (McMullan, Parush, & Momtahan,

With the evolution of healthcare, patient handovers have become not only a concern in Ontario, but an international concern. The handover (or handoff), also known as a critical transfer point, is the communication between units and healthcare teams that involves the transition of patient information. During a period of care, a patient can potentially be treated by multiple healthcare members in various clinical settings across the continuum of care. The handoff can occur between specialized outpatient, emergency, surgical, and intensive care units and include encounters with numerous staff members at each interval. Some nursing units transfer or discharge their patients at a rate of 40-70% everyday (Friesen, White & Byers, 2009). Consequently,

Communication plays a vital role in the healthcare setting, as the relationship with the healthcare professional sets the tone of the care experience and has a powerful impact on patient satisfaction. It is “the shared process in which messages are sent and received between two or more people which are made up of a sender, receiver, and message in a particular context” (cite, date). This essay highlights the importance of, and some common barriers to, effective communication in the healthcare setting. It involves many interpersonal skills such as effective observation, questioning and listening, giving feedback, recognizing and removing barriers.

I have looked through my emails and do not find evidence that you sent a pre and post PaperRater report for this assignment. Had you done that, it would have helped you correct one or two spelling errors. As with all writing tools, it would have made some suggestions that were not applicable. But more importantly it would have shown you some of the weakness in your writing style that you could have applied to a revision.

Communication is a vital element in the effectiveness of any hospital. Successful use of communication allows healthcare professionals to understand and connect with the people around them, build respect and trusting relationships, and foster environments where clinicians can problem solve collectively and care for patients. A recent study conducted by the Joint Commission (2016) indicated that communication errors were the one of the top three root causes of sentinel events consistently year after year. These sentinel events could have been possibly avoided if the healthcare team would have used communication in an effective way. The purpose of this paper is to not only educate the reader on the relationship between communication and

Now that we have examined numbers in the aspect of the big picture, it is important to narrow it down to gain some perspective and to also experimental see if we can determine if the previous numbers could indeed be credible or not. I discovered an article dealing with deaths per year due to miscommunication based strictly from hospitals that are affiliated with Harvard University. In this study, 23,658 malpractice cases from 2009 to 2013 were examined and found that 7,000 cases involved communication failure between medical staff or doctor and patient. Within these cases it was determined that 1,744 deaths per year occurred due to communication related issues. This equates to approximately 30% of cases having communication failure that

Opener: Approximately 80% of healthcare errors are due to lack of communication. Whether that is patient to nurse, nurse to nurse, nurse to provider, provider to patient, provider to provider, these errors are likely to have life-long effects on patients and their family members.

Ineffective communication is a prominent contributor to patient harm in hospitals. Recently, there has been a growth of research that indicates that clinical handover is a critical site for communication errors, that can subsequently lead to patient harm. According to Eggins & Slade (2015), a recent European Commission project recognized handover communication to be responsible for 25% to 40% of adverse events. This suggests that there is ineffective communication at some point during the handover period. Clinical handover can be defined as the transfer of accountability and or responsibility for patient care from one provider or a team of providers to another (Eggins & Slade, 2015). Thus this topic is of great interest as I have witnessed ineffective communication during the handover period that had the potential to become an adverse event, whilst on a clinical placement. For that reason, a quality improvement initiative of bedside handover should be implemented to reduce the risk and potentially prevent patient harm. This essay will articulate and justify a healthcare quality improvement initiative based on observations seen out on clinical placement. Firstly, it will express and give reason to the quality improvement initiative of bedside handover; it will then apply Kurt Lewin’s 3-Step Model for Change theory whilst using the initiative of bedside handover and finally, propose an evaluation plan to see the effectiveness of the quality improvement