Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety

TLDR

Suboptimal information exchange in healthcare leads to patient harm, with communication errors cited as a leading cause of sentinel events and accounting for 70 % of adverse events, yet existing safety strategies fail to address the complex sociotechnical barriers that make communication a persistent challenge. The study calls for a detailed dissection of communication errors—using root cause analysis, failure modes and effects analysis, or event reporting—to enable precise categorization and focused interventions for patient safety. By defining specific communication barriers and mapping evidence‑based recovery strategies to each, the authors propose a targeted approach that enhances the reliability and validity of information exchange in healthcare.

Abstract

Abstract Suboptimal exchange of information can have tragic consequences to patient’s safety and survival. To this end, the Joint Commission lists communication error among the most common attributable causes of sentinel events. The risk management literature further supports this finding, ascribing communication error as a major factor (70%) in adverse events. Despite numerous strategies to improve patient safety, which are rooted in other high reliability industries (e.g., commercial aviation and naval aviation), communication remains an adaptive challenge that has proven difficult to overcome in the sociotechnical landscape that defines healthcare. Attributing a breakdown in information exchange to simply a generic “communication error” without further specification is ineffective and a gross oversimplification of a complex phenomenon. Further dissection of the communication error using root cause analysis, a failure modes and effects analysis, or through an event reporting system is needed. Generalizing rather than categorizing is an oversimplification that clouds clear pattern recognition and thereby prevents focused interventions to improve process reliability. We propose that being more precise when describing communication error is a valid mechanism to learn from these errors. We assert that by deconstructing communication in healthcare into its elemental parts, a more effective organizational learning strategy emerges to enable more focused patient safety improvement efforts. After defining the barriers to effective communication, we then map evidence-based recovery strategies and tools specific to each barrier as a tactic to enhance the reliability and validity of information exchange within healthcare.