Using Incident Reports to Assess Communication Failures and Patient Outcomes

Jt Comm J Qual Patient Saf. 2019 Jun;45(6):406-413. doi: 10.1016/j.jcjq.2019.02.006. Epub 2019 Mar 29.


Introduction: Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes.

Methods: Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test.

Results: Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes.

Conclusion: It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Communication*
  • Humans
  • Medical Errors / prevention & control*
  • Patient Safety*
  • Retrospective Studies
  • Risk Management*