Root Cause Analysis: Communication Errors

EDITOR'S NOTE: Special thanks to Kate Leatherby for writing today's blog post. You can connect with her on LinkedIn. 

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Ever since I started working for Pulsara, self-reflection about communication has become an almost daily ritual. Reflecting on my career, it’s very apparent that when things haven’t gone right with projects, patient care, presentations, etc., a miscommunication of some sort has been the likely culprit.   

Reliable communication in healthcare is essential to quality patient care, and when gaps exist, it is costly to both patients and organizations. 

A study published in the peer-reviewed healthcare journal BMJ Quality and Safety in 2011 aimed to review the root cause analysis report (RCAR) for the characteristics of communication errors between hospital staff members.

Of the 84 RCA’s evaluated that were related to severe patient safety issues, 44 (52%) were found to have a root cause due to or related to verbal communication errors. Of those:

• 35 (86%) involved communication errors during patient handoff
• 19 (43%) involved communication errors between different staff groups 
• 13 (30%) involved misunderstandings between care team members 
• 11 (25%) involved communication errors between junior and senior staff members 
• 10 (23%) involved a care team member's hesitance to speak up
• 8 (18%) involved communication errors during teamwork 

The study also found that non-proceduralized communication via the telephone to transfer care between units or consult with other specialties was the most vulnerable scenario for communication errors.

Understanding this information is the first step in making progress towards improving the way we communicate. When we have fragmented, siloed communication, we leave ourselves vulnerable to critical and very costly communication errors. 


So, with that understanding, here are my three recommendations to mitigating communication errors within your organization:

1. Continuous process evaluation and improvement.

Stay a step ahead by evaluating your process when things appear to go well, not just when they go wrong. There are always opportunities to improve, no matter how well something goes.

2. Be open to constructive feedback.

Our perception of our performance can sometimes differ from reality, so it’s essential to be open to others’ feedback to be the best team player we can be.

3. Prioritize development of better communication skills. 

Soft skills involved in communication can be challenging to develop unless we are committed to making the adjustments needed to improve our skillset. There are dozens of free online webinars out there that are directed at the development of soft communication skills.

Decreasing communication errors starts with us as individuals. A little self-reflection can go a long way in initiating the change needed to improve our ability to communicate effectively.

Works Cited

Rabøl LI, Andersen ML, Østergaard D, et al. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals BMJ Quality & Safety 2011;20:268-274.

Providing efficient and high-quality care for patients is all about identifying bottlenecks and weaknesses while eliminating mistakes. Learn how to coordinate your care teams like a professional pit crew in Putting a [Pit]Stop to Bottlenecks in Healthcare Communication.