Poor communication from healthcare practitioners contributes to about one quarter of patient safety incidents in hospitals and is the only identifiable cause for one in 10 incidents, a systematic review has revealed.
The findings suggest the need for interventions to improve patient safety, such as evidence-based communication training spanning the continuum of healthcare careers, according to University of Leicester researchers in the UK.
The team examined adverse events, near misses, medical errors, and medication errors from 46 studies published between 2013 and 2024 involving 67,826 patients, including some from Australia.
Types of communication included verbal, written, electronic and nonverbal between different practitioners and between practitioners and patients.
Findings published in Annals of Internal Medicine [link here] showed that poor communication directly caused a median of 13.2% of safety incidents based on four studies looking at poor communication as the only identified cause.
The remaining 42 studies investigated whether communication problems contributed to patient safety incidents alongside other causes; with poor communication contributing to a median of 24% of safety incidents.
In one instance a physician accidentally shut off a patient’s amiodarone drip while trying to silence a beeping pump. The physician did not notify the nurse the drip was stopped, leading to the patient having a dangerously high heartbeat.
In another case, a patient died after a nurse did not explain to a surgeon that the patient was experiencing abdominal pains following surgery and had a low red blood cell count, indicative of internal bleeding. The patient later died from the haemorrhage that could have been prevented with adequate communication.
The authors said that because the results were broadly comparable across cultural contexts, shared problem-solving internationally might help address the threat poor communication posed to patient safety.
“Our findings highlight the crucial need for healthcare professionals to develop and maintain effective communication skills to foster strong relationships with their peers and their patients,” the researchers said.
“Policymakers should therefore focus on commissioning evidence-based training to ensure that healthcare professionals develop and maintain positive communication and teamwork, which can consequently improve healthcare safety. Such training should span the continuum of health professions education, from undergraduate training to continuing professional development, and should consider effective communication skills between all relevant stakeholders, including patients, healthcare professionals, and non-clinical staff.
“This is particularly important given that 30 of the 46 included studies revealed that communication between colleagues contributed to patient safety incidents.”