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THE WEAKEST LINK INTER-ORGANISATIONAL COMMUNICATION ABOUT (NEAR-) INCIDENTS IN THE HEALTH CARE CHAIN
Abstract and Figures
Where people work, things may go wrong, mistakes happen, and systems fail. The health care system is an example of a complex environment, where mistakes happen. Worst-case scenario, patients die because of things that go wrong, because of (near-) incidents. As many researchers have argued, learning from (near-) incidents depends mainly on insufficient intra-organisational communication. Professionals need to be informed of what had happened. Professionals need to communicate to each other about (near-) incidents to avoid at least the negative outcomes.
Within the health care chain, professionals from different organisations and disciplines contribute within a linking system to the care of patients. Incidents in one link, e.g., the ambulance service, can have consequences for the delivery of care in another link, e.g., the hospital. Alternatively, incidents can be discovered later on in the chain. To learn from (near ) incidents that happen in other links, professionals need to share information between organisations. Professionals need to communicate between organisations to create inter-organisational learning.
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... To improve transitional patient safety, it is vital that healthcare professionals in primary and secondary care understand each other's working methods, and practice good communication and openness [10]. Many emphasize the need for a system-based approach in healthcare in which the patient has a central role [11,12]. ...
Introduction: Patient transitions between primary and hospital care include referral, discharge, and simultaneous care by the outpatient clinic and the general practitioner (GP). Research on referrals and discharge shows that safety incidents in these transitions are common. We developed the multifaceted Transitional Incident Prevention Programme (TIPP), which aims to improve transitional patient safety preventing future incidents. With this study, we aim to evaluate the effectiveness of the TIPP programme on transitional patient safety, and to evaluate its implementation and the acceptance in GP-practices and hospitals. Methods: The TIPP intervention study is a controlled before and after study combined with qualitative methods. The study will be conducted in both rural and urban settings including three hospitals, together with referring primary care practices. The TIPP intervention is aimed at three aspects of transitional safety: 1) Healthcare process, 2) Transitional patient safety culture, and 3) Patient participation. Together with the participating hospital departments, GPs and patients, we will develop a tailored improvement programme, taking into account the different context of each setting.
Objectives: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. Design: Cross sectional surveys. Setting: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. Participants: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). Main outcome measures: Perceptions of error, stress, and teamwork. Results: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. Conclusions: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
It is often said that the practice of management is in crisis, and that managers are now finding it harder than ever to develop strategies which withstand the shocks of the marketplace. This illuminating book cuts through these conflicting issues to show how organizational communication plays a vital role in confronting uncertainty. Arguing that many managers fail to adequately consider the communication consequences of the decision making process and its impact on organizational effectiveness, Hargie and Tourish present here numerous organizational communication insights, and show how they reveal a way through these dilemmas. Based on cutting-edge research findings and case studies, this book features contributions from the UK, USA, Canada, New Zealand and Norway, bringing multiple perspectives to this topical subject. The result is a comprehensive guide to organizational communication useful for managers, academics and students. © 2004 Selection and editorial matter, Dennis Tourish and Owen Hargie. All rights reserved.
The abstract for this document is available on CSA Illumina.To view the Abstract, click the Abstract button above the document title.
A new genre of case methodology is described that can be used to help participants diagnose and increase their competence in helping themselves and others to become more effective leaders, learners, and facilitators of double-loop change. The case methodology can, at the same time, test features of theory using a quasiexperimental approach.
Background
Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR.
Methods
Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions.
Results
421 communication events were noted, of which 129 were categorized as communication failures. Failure types included “occasion” (45.7% of instances) where timing was poor; “content” (35.7%) where information was missing or inaccurate, “purpose” (24.0%) where issues were not resolved, and “audience” (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error.
Conclusion
Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.