Media release

From: American College of Physicians

Poor communication causes one in 10 patient safety incidents in hospitals
Abstract:https://www.acpjournals.org/doi/10.7326/ANNALS-24-02904
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A systematic review of studies quantifying the effect of poor communication on patient safety found that a quarter of patient safety incidents are attributed to poor communication from health care professionals. The findings highlight the need for health care professionals to develop and maintain effective communication skills to foster relationships with peers and patients. The findings are published in Annals of Internal Medicine.

A team of researchers from the University of Leicester examined 46 studies including patients from Europe, North and South America, Asia, and Australia, which comprised incidents involving 67,639 patients, published between 2013 and 2024. The included studies quantified patient safety incidents, included health care practitioners from any discipline, and evaluated communication between health care staff and between health care staff and patients or caregivers. The types of patient safety incidents measured across studies included adverse events, near misses, medical errors and medication errors. Methods of communication evaluated included verbal, written, electronic and nonverbal. Incidents reviewed within the study include a physician who accidentally shut off a patient’s amiodarone drip while trying to silence a beeping pump. The physician failed to 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 had failed to explain to a surgeon that the patient was experiencing abdominal pains following surgery and had a low red blood cell count, which is indicative of internal bleeding. The patient later died from the hemorrhage that could have been prevented had there been adequate communication. Overall, the review found that poor communication contributed to 25% of patient safety incidents and was the only identified cause in one in 10 incidents. The findings suggest the need for interventions to improve patient safety through improved communication. Such interventions include policymakers commissioning evidence-based communication training to health care professionals that spans the continuum of health professions education. The authors also note that because the results are broadly comparable across cultural contexts, there is a need for shared problem-solving internationally to address the threat poor communication poses to patient safety.