Safety-critical communication

Abstract

In Chapter 1 we highlighted an example of failed handover in a tragic case report. This example underscores the difficulty that doctors, as a craft group, often have when we try to talk about communication problems. When trying to explain why an adverse event has occurred, we frequently invoke ‘poor communication’ as a contributing factor. Deeper discussion, however, often proves to be a woollier beast, and we often retreat to the comforting realm of the technical, where the landscape is reassuringly familiar and the outlines are, for us, more clearly defined. Unfortunately the mammoth in the room cannot be ignored; under systematic scrutiny, ‘communication failure’ consistently represents one of the lead contributors to serious adverse events. Most recently, analysis of AIMS report data in an Australian area health service revealed that communication problems were the largest single contributing factor to severe and/or life-threatening clinical incidents over a 2-year period (2007–2009). Perhaps if we develop a better vocabulary of the types of communication errors that occur commonly in the workplace, we can be more articulate about them and develop more focused strategies to overcome them. Communication can be defined as the transfer of meaning from one person to another. For the purposes of developing practical communication tools, communication can be broken down into a package of signals sent from one person—the transmitter— to another—the receiver. These signals are both verbal and non-verbal. It is essential to realize that as social beings we are all constantly ‘transmitting’ signals—not just in the content of our words, but the types of words we use, the tone of our voice, our facial expressions, our body language, our physical proximity to others, the way we dress, the material possessions we display, etc. At any one time most of us are only partly conscious of the total package of what we are ‘saying’ to others. At the same time we are constantly receiving signals and, to a greater or lesser extent, trying to read meaning into and ‘make sense’ of these perceptions. Again often we are only partly conscious of the meaning of the ‘vibes’ we receive; yet they can have a profound impact on what we hear from others.

A proposed system for standardization of colour-coding stages of escalating criticality in clinical incidents

“…The ErroMed model of error management [28,29] was influenced by Helmreich's Threat and Error Management (TEMs) model [30], the US military's Defence Readiness Condition (DEFCON) classification system [31] and the American Society of Anaesthetists' ASA grading system [32]. The three classification systems are compared in Fig.…”

“…In the ErroMed model [29], colour is used to denote both a state of criticality and the priorities of action. Green denotes a 'routine' or 'safe' state, where the priority is to proceed, while avoiding known hazards.…”

The Bowtie diagram: a simple tool for analysis and planning in anesthesia

“…The authors had developed the diagrams in the years leading up to the following meetings where they were independently presented. These included the Australian Society of Anaesthetists (ASA) National Scientific Meeting (NSC) 2012 [ 13 ], Australian and New Zealand College of Anaesthetists (ANZCA) Annual Scientific Meeting (ASM) (Singapore 2014) and the New Zealand Society of Anaesthetists (NZSA) ASM (Dunedin 2013). The principles of the Bowtie diagram [ 6 ] and an example depicting hypertension during anesthesia were published in 2016 [ 7 ].…”

“…The Resilient Anaesthetist model [ 13 ] used the principles of a fault tree but stressed that prior to the critical event that there is still an opportunity to escalate attempts to avoid the incident and finally, immediately prior to the critical event and when it is inevitable, that there is still an opportunity for mitigating the outcome. It should be also noted that mitigation and immediate management of an event may be a continuous process, but once a certain point is passed, then it is not possible to turn back to a position prior to a critical event.…”

“…Once the management of the event is complete, it is possible to reach a new zone of stability, but it is not completely the same zone as prior to the event and there might be harm that is present but not detectable clinically at that point in time. The Vortex [ 13 ] is a similar analogy relating to the vortex of a plug hole in a sink or bath. Again, at the top of the vortex, there is a possibility of escaping the whirl of the vortex, but once entering the whirlpool at some point, there is no possibility of avoiding being sucked into the vortex created.…”