Approach to Improving Patient Safety: Communication
Each one of the countless necessary communication points between providers and between providers and patients or family caregivers represents an unwelcome opportunity for a patient safety event. During a year when society has been focused on limiting the number of in-person interactions due to the risk of COVID-19, there is a need to acknowledge and prioritize the critical role communication still plays in the safe delivery of healthcare. In 2020, researchers explored current challenges to effective communication with patients, the impact of different techniques to improve communication between providers and with patients, and lessons learned from communication practices during the COVID-19 pandemic that may have applicability beyond the pandemic.
This annual perspective includes the contribution of Dr. Jeffery Schnipper, a subject matter expert in care transitions and communication among healthcare providers and between patients and providers. Perspective authors reviewed articles related to communication and patient safety added to the AHRQ PSNet Collection in 2020. Key themes and findings identified by researchers are highlighted below.
Communication with Patients
When engaging and caring for patients, effective communication is an essential duty of a provider and paramount for shared decision-making and patient-centered care. Communication throughout a patient’s interaction with the health care system, including during diagnosis, treatment, and transitions to other settings of care including the home, helps to ensure patients and family caregivers can participate effectively in their care and make informed decisions. However, when these communication touchpoints are not optimal or are missed altogether, there is an opportunity for harm. For example, one study found that during the diagnosis process in the emergency department (ED), 23% of patients did not receive an explanation of their health problem upon discharge, and one-quarter of those patients did not understand the next steps after leaving the ED, including what to do if a condition gets worse or doesn’t improve. These types of communication breakdowns can lead to an adverse event and harmful consequences.
Effective communication can have a profound impact on how patients and caregivers perceive their care. A survey found that patients consider poor communication to be one of the main causes underlying diagnostic error. Conversely, parents of neonates in the NICU perceive care being safer when clinicians communicate with them, in addition to being present, intentional, and respectful when adhering to safety practices. Open communication between the medical team and patients and families can broaden perspectives, provide new information, and reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error or avoidance of medical care in general. However, it can also bring the challenge of potential conflicts in perspectives between providers and families and questions about how best to handle heightened emotions and the potential for distrust.1
In 2020, a number of different strategies were reviewed to not only support communication between patients and providers, but also to use that communication as a means to include patients in the identification and avoidance of adverse events. For instance, health information technology (HIT) provides powerful avenues for connecting directly with patients. Facilitating patient access to their electronic health record (EHR) can give them the ability to review and report errors in the medical notes.2,3 Expanded patient access to EHRs also presents the opportunity to solicit patient-reported outcomes via embedded surveys.4 Providing patient access to the EHR has been effective at improving some clinical outcomes, but when designing the interactive dashboard, researchers note that developers should ensure appropriate messaging for patients, that the dashboard promotes actions, and that information is accessible for the lay person.
In addition to the use of HIT, research released in 2020 highlights interventions to address communication challenges caused by human error, predominantly associated with ensuring appropriate patient comprehension and understanding of instructions and care information. For example, in the development of advance care planning documentation, one study concluded that interventions should address human-dependent issues that can result in communication-related safety events, such as incomplete documentation or miscommunication. More discrete interventions include the use of discharge education programs and simplified discharge information cards to increase patient awareness and to support communication during this critical patient transition period. Reducing the complexity of discharge information takes into greater consideration the limited health literacy among some patients and reduces the potential for miscommunication and poor patient understanding. In some cases, interpreters may also be necessary to help to reduce language barriers and support more timely communication and safer care, particularly in vulnerable populations.
Communication across Providers
Communication, and teamwork in particular, are pillars of patient safety culture. More frequent communication contact between leaders and members of their team is associated with better patient safety culture. However, as with provider to patient/caregiver communication, breakdowns in communication among providers are a common source of error that can result in adverse events, particularly at patient transition points. For instance, one systematic review found that timely communication of discharge summaries between hospital-based and primary care physicians was low, and that almost 10% of discharge summaries were never transferred. This type of inadequate communication at handoffs contributes to adverse events, including medication errors. Poor provider communication is a common contributor to errors of omission related to medication safety, and one study found that inadequate communication among providers is a common contributing factor in diagnosis-related and failure-to-monitor malpractice claims.
Structured Communication Techniques
The use of structured and codified communication practices can help to ensure consistent communication across providers and alleviate the risk of adverse events stemming from communication breakdowns. For example, interdisciplinary bedside rounding approaches bring together clinicians with the goal of sharing patient information and collaborating on a plan of care. These practices have been shown to have a positive impact on outcomes, including readmissions. Different team huddle approaches help providers avoid cognitive errors by allowing colleagues to confer during clinical decision-making. They can also serve as a means of sharing information and problem solving at all levels of the organization. Training content, such as I-PASS, TeamSTEPPS, simulation-based closed-loop communication, and speaking up skills present trainees with different approaches to integrate structured and purposeful communication in institutions. When such approaches are used, it can decrease misconceptions and misunderstanding between nursing and medical teams and lessen the risk of medical errors. However, some researchers have concluded that insufficient evidence exists to truly assess the benefit of huddles, as the majority of studies use uncontrolled pre-post study designs, and there are challenges associated with demonstrating the benefit on factors such as healthcare utilization.
HIT can be a powerful tool to support structured communication processes among providers, particularly through the inclusion of structured note templates in the EHR and automated abstraction of data. However, the use of HIT is not a perfect solution, and articles in 2020 highlighted several pitfalls and challenges associated with the over-reliance on electronic asynchronous communication across providers. Using HIT for communication can cause care delays, resulting from factors such as: the need to manage electronic health record inbox notifications and communications, the burden of gathering key diagnostic information, technical problems, data entry problems, and system failures with tracking test results. Similarly, nurses and providers may use secure text messaging to communicate, but research has highlighted concerns about alarm fatigue, communication errors, and the omission of critical verbal communication. Other research assessing the impact of computer-mediated handovers has also concluded that oral communication is still an essential component of effective and accurate communication across providers and that it should not be overlooked as the use of HIT continues to increase.
Lessons Learned from COVID-19
During the COVID-19 pandemic of the past year, the healthcare workforce has faced unprecedented challenges that have required innovative, creative, and agile responses to difficult and dynamic environments on the frontlines of care. Communication across providers is one of many functions that has adapted during this period in order to accomplish medical distancing and react to other changes. Articles published in 2020 highlighted a number of promising communication practices implemented in response to COVID-19. Examples include:
- Broad inclusion of interdisciplinary teams for intensive collaboration and the identification of innovative approaches to care.
- Transparent decision-making and continuous communication with the workforce, using all communication modalities available.
- Distance communication with interdisciplinary team members facilitated by technology, enabling more seamless integration into everyday rounding and huddles, and the inclusion of family caregivers.
- Expanded use and functionality of telemedicine to allow for remote diagnosis and communication with the patient.
- Interdisciplinary community learning through popular social media platforms.
As usual care resumes, institutions may find that many or all of these examples have the potential to improve communication practices and the safety of care well beyond the current pandemic.
Despite the challenges faced this year and an emphasis on promoting physical distance, publications in 2020 have demonstrated that persistent efforts continue to evaluate and improve healthcare communication. Some of these efforts have been in direct response to changes imposed by the COVID pandemic. Moving forward, specific areas and considerations identified in the literature underscore the need for future research. The first is the need for better tools and approaches for communicating medication safety with patients. Success will likely rely on using a combination of patient/family-centered HIT and pharmacist-led counseling, coaching, and follow-up. For example, a survey of over 500 OB/GYNs indicated an opportunity to improve available tools for communicating about pregnancy-related medication safety. The second is the need to develop effective transition tools that align with the requirements of the Caregiver Advise, Record, Enable (CARE) Act, in particular noting information about the patient’s family members and communicating with them prior to patient discharge back to the community. Finally, research is needed to better understand communication approaches applied during the COVID-19 pandemic and test them as part of usual care. Looking ahead, as health care delivery seeks a better ‘new normal,’ we need to learn more about communication practices and their feasibility, efficiency, and impact on safety outcomes. While the pandemic inflicted catastrophic consequences on victims and those who care for them, lessons learned about optimal communication during the pandemic hold promise for improvements in the future. Advances in HIT will certainly be part of a successful strategy, but only if it is well-designed with awareness that it is not a panacea. Research findings suggest that well-informed solutions that effectively combine both “high-touch” and “high-tech” are needed to address the pervasive, complex communication challenges still facing healthcare.
Jeffery L Schnipper, MD, MPH
Research Director, Division of General Internal Medicine and Primary Care
Director of Clinical Research, Brigham Health Hospital Medicine Unit
Professor of Medicine, Harvard Medical School
Eleanor Fitall, MPH
Senior Research Associate, IMPAQ Health
Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
Bryan Gale, MA
Senior Research Analyst, IMPAQ Health
2. Bell SK, Delbanco T, Elmore JG, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Netw Open. 2020;3(6):e205867. doi: 10.1001/jamanetworkopen.2020.5867. [PSNet]