Neil and HIFA Colleagues
Reliable communication is a key factor in access to reliable health care information, and indeed in most aspects of health care. Several of the responses to the HIFA spotlight on patient safety have mentioned communication problems as important risk factors.
Although I am well aware of the hazards of reading too much into individual experience, sometimes the occurrence of only a few instances of an observation can be of more general significance (it only takes one drop to know that seawater is salty!). With that, and
Neil’s request for personal examples , in mind, I offer the following observations.
In my or my family’s fairly recent personal interactions with the health services (in the UK) there has been:
- Misidentification/wrong name (twice!)
- Failure to warn of a potentially fatal adverse reaction to medication
- Omission of discussion of important recommended treatment options
- Late communication of health care information
- Treatment information not being passed on between health professionals
These may be problems at the individual or at the system level – poor record keeping and transmission systems, uncoordinated teams, overworked staff etc – but either way the effect is the same – otherwise good health care - and so patient safety - being put at risk by communication failures.
There is ample evidence that this is not just my experience. The seminal 2004 study “Communication Failures: An Insidious Contributor to Medical Mishaps “ by Kathleen M Sutcliffe et al . (http://doi.org/10.1097/00001888-200402000-00019 ) reported that communication was one of the top cited contributing factors to mishaps. More generally the recent literature review by Keshtkar et al. (2025), “Impacts of Communication Type and Quality on Patient Safety Incidents: A Systematic Review.”
( https://www.acpjournals.org/doi/10.7326/ANNALS-24-02904 ) looked at over 67,000 patients and found that poor communication alone caused 13% and was a contributory factor in 24% of safety incidents. At an estimated one in 10 patients being subject to an adverse event while receiving hospital care in high-income countries, and more than 130 million adverse events due to unsafe care occurring in hospitals in low- and middle-income countries alone (ref :“Global Patient Safety Action Plan 2021–2030) that is a lot of harm related to communication deficiencies.
The WHO publication “Global Patient Safety Action Plan 2021–2030:Towards eliminating avoidable harm in health care” does make some reference to communication issues, in particular:
“ ….. research and patient safety incident reports show that patients’ conditions are often misdiagnosed because of clinical misjudgements, or when the correct test is not carried out or test results are lost, or because of miscommunication between different parts of the same health care system, among other reasons. Prominent among these reasons is the failure to communicate well with the patient.”
and
“ …. incorrect patient identification is responsible for medication errors and wrong site, wrong patient surgery. Improving critical communication amongst health workers and with patients is crucial and would prevent millions of adverse events.”
However, the Action Plan says little about steps to mitigate such problems. Increasing attention to reducing deficiencies in communication in healthcare practice seems likely to offer significant gains to patient safety.
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geoff.royston@gmail.com
07531 125436
HIFA profile: Geoff Royston is an Independent Health Analyst and Researcher, former Head of Strategic Analysis and Operational Research in the Department of Health for England, and Past President of the UK Operational Research Society. His work has focused on informing the design, implementation and evaluation of policies and programmes in health and social care, and on fostering the capabilities of others to work in these areas. Associated activities have included modelling for understanding the performance of complex systems, analysis and communication of risk, and horizon scanning and futures thinking. He has also worked on information and communication technology in the health sector, notably in leading the design and national launch of the telephone and online health information and advice service NHS Direct. He has served on both scientific and medical UK Research Council panels, and as an impact assessor for the UK higher education Research Excellence Framework. He is a member of the editorial board for the journal Health Care Management Science and in 2012 was Guest Editor for its special issue on Global Health. He has been a consultant for the World Health Organisation, is a long standing member of the EURO Working Group on Operational Research Applied to Health Services, and is an expert adviser to the mHIFA (mobile Healthcare Information for All) programme. http://www.hifa.org/projects/mobile-hifa-mhifa He is also a member of the main HIFA Steering Group and the HIFA working group on Evaluating the Impact of Healthcare Information.
http://www.hifa.org/support/members/geoff
geoff.royston AT gmail.com