Investigating Approaches to Reduce Communication Related Patient Adverse Events
Examining Why the Pattern of Miscommunication and Other Associated Factors are Going Undetected
The two-phase study analyses actual adverse patient events in Hong Kong that are linked to communication. The research categorises communication channels associated with common patient error events. Identifying where communication events are most likely to occur enables processes to be put in place to reduce the likelihood of patient harm. In addition, identifying clinician strengths and how error and patient harm is avoided was examined in phase 2. Learning from good practice rather than on focusing on error is the second aim of this research.
Project PI: Prof. Bernadette Watson
This project had two phases. In Phase 1, we analysed data from Risk Alert and Annual Reports on Sentinel Events (SEs) issued by the Hong Kong Hospital Authority. Of the 235 SEs investigated, 189 (over 80%) were associated with communication failure. The highest incidents of communication error occurred with joint written and spoken communication, followed by written communication. For example, the former occurred when team roles during theatre operations were not clearly delineated and staff did not check procedures with other team members. This, in turn led to inaccurate written documentation. Written communication failures were mostly related to documentation and guidelines or principles, in adverse events. Drug prescription mistakes were an example of written only communication causing patient harm. The research shows that clinicians investigating the SEs focus on the specific factors of each incident and make recommendations to address the behaviours that occurred in that SE. The result is accurate but limited recommendations. More attention must be given to antecedents to each event, alongside the actual culture of hospitals that influence communication. We acknowledge the importance of clinical expertise with respect to investigating SEs. However, we propose the complexity of SEs requires the input of social scientist investigative expertise to find commonalities across events that will complement clinician recommendations beyond offering communication skills training and so will reduce SEs. 
Phase 2 involved interviews with a diverse range of health professions and sought to identify clinician strengths that demonstrate best practice to ensure quality patient care. Phase 2 builds on Phase 1 and investigates the facilitators of quality patient care in order to recognise when and why events go well and patient harm is avoided.