Kerm Henriksen

Communication Failure: Basic Components, Contributing Factors, and the Call for Structure

BACKGROUND Communication is a taken-for-granted human activity that is recognized as important once it has failed. Communication failures are a major contributor to adverse events in health care. BASIC COMMUNICATION COMPONENTS AND PROCESSES The components and processes of communication converge in an intricate manner, creating opportunities for misunderstanding along the way. When a patients safety is at risk, providers should speak up (that is, initiate a message) to draw attention to the situation before harm is caused. They should also clearly explain (encode) and understand (decode) each others diagnosis and recommendations to ensure well coordinated delivery of care. INDIVIDUAL, GROUP, AND ORGANIZATIONAL FACTORS Beyond basic dyadic communication exchanges, an intricate web of individual, group, and organizational factors--more specifically, cognitive workload, implicit assumptions, authority gradients, diffusion of responsibility, and transitions of care--complicate communication. THE CALL FOR STRUCTURE More structured and explicitly designed forms of communication have been recommended to reduce ambiguity, enhance clarity, and send an unequivocal signal, when needed, that a different action is required. Read-backs, Situation-Background-Assessment-Recommendation, critical assertions, briefings, and debriefings are seeing increasing use in health care. CODA: Although structured forms of communication have good potential to enhance clarity, they are not fail-safe. Providers need to be sensitive to unexpected consequences regarding their use.

Improving the Health Care Work Environment: A Sociotechnical Systems Approach

This issue examines findings on key elements of the hospital environment, identifies risks to safety and quality, and proposes operational and policy solutions.

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

Abstract Background: The Improving Diagnosis in Health Care report from the National Academies of Sciences, Engineering and Medicine (NASEM) provided an opportunity for many groups to reflect on the role they could play in taking actions to improve diagnostic safety. As part of its own process, AHRQ held a research summit in the fall of 2016, inviting members from a diverse collection of organizations, both inside and outside of Government, to share their suggestions regarding what is known about diagnosis and the challenges that need to be addressed. Content: The goals of the summit were to learn from the insights of participants; examine issues associated with definitions of diagnostic error and gaps in the evidence base; explore clinician and patient perspectives; gain a better understanding of data and measurement, health information technology, and organizational factors that impact the diagnostic process; and identify potential future directions for research. Summary and outlook: Plenary sessions focused on the state of the new diagnostic safety discipline followed by breakout sessions on the use of data and measurement, health information technology, and the role of organizational factors. The proceedings review captures many of the key challenges and areas deserving further research, revealing stimulating yet complex issues.