Identifying and Classifying Communication Failures: Developing - - PowerPoint PPT Presentation

Identifying and Classifying Communication Failures: Developing Methods to Reduce Communication-Related Incidents

Milisa Manojlovich, PhD, RN, CCRN1 Elizabeth Umberfield, BSN, RN1 Amir Ghaferi, MD, MS2 Sarah Krein, PhD, RN3,1,2

1University of Michigan, School of Nursing; 2University of Michigan, Medical School; 3Department of

Veterans Affairs, Center for Clinical Management Research

Acknowledgement

• Risk Management Department

Background

• Communication failures and patient safety
• “In the moment” vs. retrospective methods
• Characterizing and learning from failures
• Hospital incident reports

– Can they be used to identify failures?

Study Purpose

To develop and apply a classification method to identify and characterize communication failures between nurses and physicians from incident reports.

Study Design

• Qualitative descriptive design
• Large Midwest tertiary care health system
• Electronically captured incident reporting

system (RL6: Risk)

Population Studied

28,893 reports submitted 16,165 reports to consider for analysis 698 reports after filters applied (communication failure, RN/MD, adult) 160 hand-selected RN-MD communication failures

Conceptual Framework: Rhetoric

What is Rhetoric?

• The study of

the relationship between communi- cation and its effects.

Rhetorical Principles

• All communication has

intended/actual effects.

• All communication is

motivated by the need to identify with an audience to “achieve common ground required for a productive exchange”

Why Rhetoric?

• A rhetorical

approach shifts emphasis away from the message to action arising from it.

Halverson et al. (2011) Classification

Failure Type Definition Error of Content Information in the message was inaccurate, missing,

• r unclear

Error of Occasion Something in the physical or temporal situation/context of the message was wrong Error of Purpose Unresolved goals (implicit or explicit) of the communication event Error of Audience Appropriate individuals were not participating Error of Omission Communication was absent Error of Inappropriate Communication Communication consisted of offensive remarks or unreasonable requests

Principal Findings

• The 160 reports involved at least one communication failure.
• 40 reports (25%) contained more than 1 communication

failure.

– In the 160 reports, there were 209 failures.

• Errors of omission were the most common (28%).
• Of the 160 reports, 101 named adverse outcomes:

– Delays in care (37.6%) – Actual or potential for physical harm (20.2%) – Dissatisfaction (9%)

Error of Content

Definition  Information in the message was inaccurate, missing, or unclear. Brief Example from Text Nurse on unit was given report from OR on a patient arriving to the unit and was told that they were only on propofol and insulin. Pt arrived with vasopressin, norepinephrine, and milrinone in addition to the propofol, and insulin.

Error of Occasion: Physical

Definition  Something in the physical or temporal situation/context of the message was wrong. Brief Example from Text Per night RN: the following morning orders were never

• entered. However, they were

written at 2159 but were signed and held (the night nurse didn't see them).

Error of Occasion: Temporal

Definition  Something in the physical or temporal situation/context of the message was wrong. Brief Example from Text

An insulin infusion’ initiated from instruction from endocrinology to nursing staff and patient without an actual order being placed in chart. Advanced practice provider attempted to get information from endocrinologist, but due to delay in hearing back no order was placed until the following morning from recommendations were documented the evening before.

Error of Purpose

Definition

• There were

unresolved goals (implicit or explicit)

• f the

communication event. Brief Example from Text

On multidisciplinary rounds I (RN) brought up to attending and CCMU fellow that PICC could be a source of infection and that we should consider removing it. MDs felt that it wasn't necessary given that pt. has VAE and blood cultures have been negative. I explained my rationale for concern given vital signs and +SIRS criteria. At this time the line remains in place.

Error of Audience

Definition

• Appropriate

individuals were not participating. Brief Example from Text

Mr.*** was put on call for the OR and brought to preop. Pt was in preop for 2 hrs with family. I called the OR charge nurse to see what the delay was with pt's case. She stated she was just told that the pt was

• cancelled. Apparently the service had

decided earlier that am that they were not going to do the procedure. No communication with OR, preop or the pt that he was cancelled. Pt and family were not happy with the situation.

Error of Omission

Definition

• Communication

was absent. Brief Example from Text Physician NOT notified of patient's T38 at 7pm. [MD] Tried to tell charge nurse, no answer. Paged nurse to notify physicians

• f abnormal vital signs, no

response.

Error of Inappropriate Communication

Definition

• Communication

consisted of

• ffensive remarks
• r unreasonable

requests. Brief Example from Text

I inadvertently contaminated the corner of a sterile table. I immediately notified the scrub and told him that the towels were contaminated and his gloves and pen were

• too. He shouted, "No they're not!" and threw

the pen on the table and threw the towels on the floor. He changed his gloves but continued to use the pen. I asked him to stop, but he shouted that he was done talking to me and said he was going to write this up as anesthesia is always contaminating tables and he has to "watch us like a hawk.”

Conclusions/Implications

• Our adapted failure classification system is

useful in identifying types of failures and contributing factors.

• Incident report data could be used to make

recommendations to reduce future failures.

• Using these methods, we can design and test

interventions to improve communication.

Thank you!!

Questions? Comments? mmanojlo@umich.edu @mmanojlo