Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

Luci K Leykum; Kevin J O'Leary

Commentary

Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

August 30, 2017

Leykum LK, O'Leary KJ. Ann Intern Med. 2017;167(4):HO2-HO3.

View more articles from the same authors.

Insufficient teamwork can exacerbate communication errors and misunderstandings. This commentary explains how sensemaking can enhance communication among team members and describes strategies to promote team sensemaking.

PubMed citation

Available at

Related Resources From the Same Author(s)

A multisite study of interprofessional teamwork and collaboration on general medical services.

November 25, 2020

Health care huddles: managing complexity to achieve high reliability.

March 26, 2014

Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.

June 19, 2013

Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.

August 2, 2017

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

January 7, 2015

Hospital quality and patient safety competencies: development, description, and recommendations for use.

January 30, 2005

Assessment of teamwork during structured interdisciplinary rounds on medical units.

October 31, 2012

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

April 28, 2010

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care.

January 6, 2016

Hospitalized patients' understanding of their plan of care.

January 27, 2010

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

November 16, 2011

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

May 6, 2009

Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.

October 24, 2012

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

May 22, 2013

Patterns of nurse–physician communication and agreement on the plan of care.

June 9, 2010

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

April 20, 2011

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers.

September 23, 2020

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link.

April 5, 2006

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

March 21, 2012

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

March 16, 2011

Is "first do no harm" a lost concept in medical education?

October 4, 2006

Identification of patient safety threats in a post-intensive care clinic.

May 31, 2023

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

December 15, 2021

Effect of surgical safety checklists on pediatric surgical complications in Ontario.

April 6, 2016

Nurses' perceptions of causes of medication errors and barriers to reporting.

December 20, 2006

The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events.

March 6, 2005

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

September 21, 2011

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

December 3, 2014

Can we import improvements from industry to healthcare?

May 1, 2019

Pharmacists' medication reconciliation-related clinical interventions in a children's hospital.

April 29, 2009

Complying with the 2008 national patient safety goals.

March 26, 2008

Debunking the myth that the majority of medical errors are attributed to communication.

September 25, 2019

The complexity, diversity, and science of primary care teams.

June 20, 2018

Complications in surgery: root cause analysis and preventive measures.

July 11, 2012

Patient and consumer safety risks when using conversational assistants for medical information: an observational study of Siri, Alexa, and Google Assistant.

September 19, 2018

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study.

May 10, 2023

Performance-based payment incentives increase burden and blame for hospital nurses.

February 16, 2011

The effects of bar-coding technology on medication errors: a systematic literature review.

April 19, 2017

What is the NHS Safety Thermometer?

November 28, 2012

Doctors' experiences of adverse events in secondary care: the professional and personal impact.

February 11, 2015

Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.

July 15, 2015

The stories clinicians tell: achieving high reliability and improving patient safety.

December 2, 2015

Doctors' perceived working conditions and the quality of patient care: a systematic review.

July 17, 2019

To think is good: querying an initial hypothesis reduces diagnostic error in medical students.

July 28, 2010

Making electronic health records both SAFER and SMARTER.

July 27, 2022

Diagnostic error and clinical reasoning.

January 13, 2010

Pharmacists and health information technology: emerging issues in patient safety.

October 22, 2008

Building physician work hour regulations from first principles and best evidence.

September 17, 2008

Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate.

June 25, 2008

Residents' suggestions for reducing errors in teaching hospitals.

March 6, 2005

No excuses: the reality that demands action.

September 1, 2005

We are going to name names and call you out! Improving the team in the academic operating room environment.

June 21, 2017

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

January 2, 2008

Is physician mentorship associated with the occurrence of adverse patient safety events?

April 10, 2019

Patient safety movement: history and future directions.

February 28, 2018

Improving care teams' functioning: recommendations from team science.

June 14, 2017

Why don't we know whether care is safe?

April 10, 2013

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.

June 12, 2013

Exploring leadership within a systems approach to reduce health care–associated infections: a scoping review of one work system model.

April 17, 2019

Comparison of internal medicine and general surgery residents' assessments of risk of postsurgical complications in surgically complex patients.

November 8, 2017

Personalised performance feedback reduces narcotic prescription errors in a NICU.

March 27, 2013

Discussing harm-causing errors with patients: an ethics primer for plastic surgeons.

June 11, 2014

Disclosure of medical errors: the right thing to do.

September 1, 2010

Implementing online medication reconciliation at a large academic medical center.

September 3, 2008

Estimating hospital-related deaths due to medical error: a perspective from patient advocates.

February 22, 2017

Can residents detect errors in technique while observing central line insertions?

September 27, 2017

Using statistical text classification to identify health information technology incidents.

May 29, 2013

Conflict of interest, Dr Charles Denham and the Journal of Patient Safety.

December 3, 2014

Impact of a pharmacotherapy alerting system on medication errors.

January 23, 2013

Getting doctors to clean their hands: lead the followers.

May 30, 2012

An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety.

November 29, 2017

Quality and safety in orthopaedics: learning and teaching at the same time: AOA critical issues.

December 2, 2015

Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.

September 10, 2014

Why the nation needs a policy push on patient-centered health care.

August 18, 2010

Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis.

November 18, 2020

Investigating the causes of adverse events.

June 7, 2017

From harm to hope and purposeful action: what could we do after Francis?

July 23, 2014

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

July 28, 2010

Checklists change communication about key elements of patient care.

October 10, 2012

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009.

September 19, 2012

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

August 22, 2012

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

August 18, 2010

Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.

August 9, 2006

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

April 18, 2007

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.

August 19, 2020

The need to include assisted living in responding to the COVID-19 pandemic.

May 20, 2020

Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations.

February 13, 2019

Quality improvement through implementation of discharge order reconciliation.

June 12, 2013

Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.

February 5, 2014

Residency training at a crossroads: duty-hour standards 2010.

November 3, 2010

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis.

May 11, 2016

Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.

January 14, 2015

Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.

October 30, 2013

Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center.

October 7, 2015

Patient and family engagement: a survey of US hospital practices.

July 8, 2015

Related Resources

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

On Patient Safety.

January 28, 2023

Communication disparities between nursing home team members.

July 20, 2022

What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.

January 19, 2022

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Nursing home residents with dementia: association between place of death and patient safety culture.

January 20, 2021

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic.

October 7, 2020

Safety at the time of the COVID-19 pandemic: how to keep our oncology patients and healthcare workers safe.

May 13, 2020

Unprofessional Behavior Leads to Complications.

April 1, 2020

Medical teamwork and the evolution of safety science: a critical review.

March 11, 2020

Patient Safety Primers

Improving Patient Safety and Team Communication through Daily Huddles

January 29, 2020

Patient Safety Primers

Patient Safety 101

September 7, 2019

Reducing diagnostic errors worldwide through diagnostic management teams.

April 3, 2019

Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.

March 6, 2019

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Negative behaviours in health care: prevalence and strategies.

February 20, 2019

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

How one hospital improved patient safety in 10 minutes a day.

November 14, 2018

Implementing Optimal Team-Based Care to Reduce Clinician Burnout.

September 19, 2018

Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture.

September 12, 2018

Critical role of the surgeon–anesthesiologist relationship for patient safety.

August 22, 2018

Teamwork in healthcare: key discoveries enabling safer, high-quality care.

July 11, 2018

Drug shortages roundtable: minimizing the impact on patient care.

June 27, 2018

Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.

May 2, 2018

The gaps in specialists' diagnoses.

April 11, 2018

Perspective

Patient Safety During Hospital Discharge

April 1, 2018

Interview

In Conversation With… Harlan Krumholz, MD, SM

April 1, 2018

WebM&M Cases

Walking Patient, Missing Drain

April 1, 2018

The new diagnostic team.

November 22, 2017

See More About The Topic

Hospitals

Facility and Group Administrators

Medicine

Epidemiology of Errors and Adverse Events

Communication between Providers

Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Improving Patient Safety and Team Communication through Daily Huddles

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Improving Patient Safety and Team Communication through Daily Huddles

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site