Table 5

Subcategories of communication problems contributing to adverse events identified by the trigger tool

Communication problemNumber of events affected, n (%)DescriptionIllustrative example
Handoff communication between intraprofessional providers4 (13)Communication problems arising at the time of shift change between two providers from the same professional background (eg, nurse-to-nurse)A nurse noted a stage 1 pressure ulcer and documented this finding in her daily progress notes. This finding was not verbally communicated to the incoming nurse at shift change. The wound went unnoticed for 4 days and progressed to a stage 2 pressure ulcer
Handoff communication during in-hospital transfer3 (9)Communication that occurs at the time of patient transfer from one unit to another within the hospital (eg, intensive care unit to general medicine ward)A patient with respiratory symptoms had a nasopharyngeal (NP) swab sent to rule out influenza. The emergency department requested a transfer to a non-isolated multipatient room. The general medicine nurse stated her objection, citing the hospital policy to keep the patient under droplet isolation until the NP swab was negative. The patient was transferred despite this objection. The NP swab result was positive for influenza A. The patient exposed a number of patients and healthcare workers to influenza A (none became infected)
Interprofessional communication10 (31)Communication that takes place between two providers of different professional backgrounds (eg, physician and nurse, nurse and allied health)A nurse detected a discrepancy between the medication administration record (MAR) and the physician orders at the time of routine MAR-to-MAR checking to discontinue aspirin. The nurse did not communicate this discrepancy to the pharmacist, and so aspirin continued to be administered to the patient, delaying an invasive procedure by 4 days
Lack of a shared care plan8 (25)Coordination of care for a patient by the various health providers on the team lacks a shared vision, relating to issues such as diagnostic testing, functional assessments, discharge planning and end-of-life careThe staff physician had a conversation with a patient's son that ultimately resulted in an important shift in the philosophy of care towards palliation. This was not documented or communicated with the rest of the team, so that when the patient's nurse tried to assess the patient's vital signs, the patient's son was distressed since his wishes were not being followed
Specialist consultation3 (9)Relates to challenges faced when interacting with specialist consulting services either due to conflicting advice, lack of appropriate levels of support or timely response to requests for helpA patient with severe bleeding at the tracheostomy site was developing acute hypoxia and respiratory distress during the overnight period. The primary nurse initially could not reach the otolaryngology resident. Only after the staff physician paged did the otolaryngology resident call back, but tried to provide advice over the telephone rather than come into the hospital from home (although eventually did come in to help manage the patient)
Provider–patient communication2 (6)Problems related to provider–patient communication (eg, obtaining informed consent) or locating the proper contact information when trying to reach a patient's family memberThe team obtained informed consent for a blood transfusion from a patient with advanced dementia incapable of providing consent
Paging problems2 (6)A lack of response to a page sent to a physician either because the page was sent to the wrong physician, the physician did not call back or the physician called back but the sender did not answer the phoneThe speech language pathologist paged a resident to obtain more information about the patient's clinical condition prior to performing her assessment. She waited for an hour but the resident did not respond. She had to delay her assessment to the next day