Qual Saf Health Care 13:i85-i90 doi:10.1136/qshc.2004.010033
  • Original Article

The human factor: the critical importance of effective teamwork and communication in providing safe care

  1. M Leonard1,
  2. S Graham2,
  3. D Bonacum3
  1. 1Colorado Permanente Medical Group, Denver, Colorado, OH, USA
  2. 2California Kaiser Permanente, Oakland, CA, USA
  3. 3Kaiser Permanente, Oakland, CA, USA
  1. Correspondence to:
 Dr M Leonard
 Physician Leader for Patient Safety, Patient Safety, One Kaiser Plaza, 22nd Floor, Oakland, CA 94612, USA;


    Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common “critical language” to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.


    • Competing interests: none declared