Transitions in care represent potential weak links that couple together the complex array of care options that patients may encounter as they traverse the modern healthcare system. Errors in communication can occur at shift changes for nurses and physicians, especially house officers, between units within hospitals (in some systems multiple transfers between wards is the norm) and between facilities. Each of these transitions requires the transmittal of precise relevant information that enables the transition to go smoothly so that errors are anticipated and eliminated, or at least reduced to the bare minimum of risk. Failure to do so can have catastrophic consequences.
She said I said what?
Sometimes, even when we try to explain things very carefully the message does not really get through. I have often sensed this happening during a conversation, and usually it is due to a patient’s or family member’s lack of comprehension of what I have said, despite my well-intentioned efforts. Some patients want simple solutions and explanations and when these cannot be provided they are less attuned to comprehension and understanding of the uncertainties and more complex explanations.
Why is it so complicated when it comes to patient safety?
In real estate there is a common dictum about what most makes a property desirable – “location, location, location”. In healthcare there is also a dictum about what makes providing healthcare services so complicated – “communication, communication, communication”. Dys-communication, occurs so frequently and has so many nuances that it is often hard to fathom just how many opportunities there are for things to go wrong. What we say and how we say things to colleagues or patients and family members may lack accuracy and clarity resulting in lack of understanding and harm.
The Complexities of Diagnosis – Understanding How and Why we Fail
There is one additional element of medical and nursing education reform that we have not yet considered and that is the complexity of diagnostic processes. Transforming healthcare will require increased emphasis on diagnostic risks and professional vulnerabilities1, 2 especially as we confront the challenges that deterioration in population health and an increase in illness burden will present in the future.