Failures in communication and information transfer across the surgical care pathway: interview study

Abstract

This study suggests communication failures occur across the entire continuum of care and the participants opined that it could have a potentially serious impact on patient safety. This data can be used to plan interventions targeted at the entire surgical pathway so as to improve the quality of care at all stages of the patient's journey.

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

“…A recently published study investigating communication and handover across a surgical pathway takes a similar view, suggesting that 'any strategy that aims to improve the system of surgery should involve identifying and improving information and communication processes across the pathway'. 92 The same most likely holds for improvements in emergency care. Taking this view, we found as a result of the research conducted in research strand 1 that capacity issues and inadequate patient flows may give rise to many of the identified potential handover failures, thus contributing to threats to patient safety.…”

“…This is a critical activity informing any subsequent improvement activities. 92 To this end, we produced detailed representations of how handover is linked to clinical practice, and the different goals and functions it can serve. Taking this as the basis, we subsequently performed a systematic risk analysis to identify the most significant risks and their possible causes at each site.…”

Too busy to lead? Current challenges for German nurse leaders

“…Another important focus for German nurse leaders currently is interprofessional communication and collaboration (IPC) which can help to improve patient safety and reduce errors (Nagpal et al 2012) as well as unnecessary cost (Brenner & Bartholomew 2005 Managing skill mix or transforming workforce and service delivery…”

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

“…[65][66][67][68][69] In addition, there is variation in the delivery of medical and nursing care. 70,71 Failure in the safety of care is a particular issue for high-risk patient groups, 72,73 but all patients may be at risk of harm, for instance, from communication deficits at handover; [74][75][76][77] from low staffing, 78 especially at weekends; or because the delivery of care coincides with the influx of a new cohort of junior doctors in training. 79,80 Foundations of the problem Rising concerns about patient safety have led, in recent years, to a number of public enquiries into highly publicised failures of the health-care system, such as patient safety failings at the Mid Staffordshire NHS Foundation Trust, 81 events at the Bristol Royal Infirmary 82 and the Royal Liverpool Children's Hospital, 83 and the actions of Dr Harold Shipman.…”

“…74,75,[129][130][131][132][133] It also requires a degree of consistency in the meanings, beliefs and values that frame different health-care professionals' commitment to care. 39 Yet effective team working remains vulnerable to the adverse effects of hierarchy, 134 poor staffing, 81 enmity and conflict 30 and the human factors that give rise to team fragility.…”