Failure to Communicate

Added on Dec 9, 2015

 

Healthcare Safety

In the iconic motion picture Cool Hand Luke, our hero, Paul Newman, finds himself incarcerated at a brutal Florida prison farm where he is told by the warden (played by character actor Strother Martin) that if he follows the rules – he won’t have any problems. After Newman is apprehended following an attempt to escape, the warden utters this classic line to Newman and his fellow prisoners: “What we’ve got here is a failure to communicate.”

Healthcare leaders often believe that communication issues are the primary cause of safety events. However, the HPI Common Cause data from over 4,900 safety events shows that communication/ information processing issues represent a mere 6.1 percent of the overall inappropriate acts leading to safety events. The discrepancy between the belief and that data may be due to confusion with terminology. Sometimes, events are caused by true communication failures: when our written or verbal communication is not received or interpreted correctly. These can occur when we fail to use the communication clarifiers in our error prevention arsenal such as read and repeat back or phonetic/numeric clarifiers. For example, during a code situation a nurse miss-administers 50 milligrams of medication when the physician called for 15 milligrams because there was no numeric clarifier (“that’s fifteen, one-five”) and no repeat-back. In HPI’s analysis of safety events, these true communication failures are relatively rare.

More common are failures to communicate. For example:

  • • An IT analyst doesn’t communicate his concern about an unusual issue during a system upgrade which leads to a data loss.
  • • A nurse doesn’t call a physician in the middle of the night about a critical change in her patient’s condition because the doctor has a reputation for “snapping” at nurses who call at night which results in a code situation.
 

These failures are far more prevalent in healthcare safety events but we classify them as critical thinking vs. communication. Staff and physicians understand that there is a need to communicate but they allow time pressures, concerns about the power distance, or overconfidence to get in the way of that communication. Critical thinking failures account for 34.3 percent of the inappropriate acts that lead to safety events in the HPI aggregate data.

Our error prevention arsenals also contain tools to help prevent failures to communicate such as Validate and Verify and Speak Up for safety. Some questions to consider:

  • • What are the reasons for failures to communicate in your organization (power distance, short cuts, non-collaboration, etc.)? What can your organization do to address?
  • • Are you celebrating individuals who practice Validate and Verify and Speak Up for Safety and sharing their stories?
 

As punishment for his escape attempt, Paul Newman is forced to spend time in the “hot box” – a solitary cell in the blazing Florida heat. In healthcare, continued serious safety events are the consequence for not addressing failures to communicate.