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psnet.ahrq.gov/issue/how-policy-makers-can-smooth-way-communication-and-resolution-programs
December 19, 2018 - Commentary
How policy makers can smooth the way for communication-and-resolution … How policy makers can smooth the way for communication-and- resolution programs. … How policy makers can smooth the way for communication-and- resolution programs. … December 19, 2018
Communication-and-resolution programs: the challenges and lessons learned … December 19, 2018
Case outcomes in a communication-and-resolution program in New York
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psnet.ahrq.gov/issue/communication-elements-supporting-patient-safety-psychiatric-inpatient-care
July 01, 2013 - Study
Communication elements supporting patient safety in psychiatric inpatient care … Communication elements supporting patient safety in psychiatric inpatient care. … In this study, researchers interviewed psychiatric nurses to explore how they conceptualize communication … Communication elements supporting patient safety in psychiatric inpatient care.
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psnet.ahrq.gov/issue/huddles-and-debriefings-improving-communication-labor-and-delivery
February 13, 2013 - Review
Huddles and debriefings: improving communication on labor and delivery. … Huddles and Debriefings: Improving Communication on Labor and Delivery. … This commentary discusses huddles as a strategy to reduce communication errors and debriefings as … Huddles and Debriefings: Improving Communication on Labor and Delivery. … March 9, 2022
Speaking across the drapes: communication strategies of anesthesiologists
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psnet.ahrq.gov/issue/leadership-initiative-improve-communication-and-enhance-safety
March 11, 2009 - Commentary
A leadership initiative to improve communication and enhance safety. … A Leadership Initiative to Improve Communication and Enhance Safety. … commentary discusses how one hospital implemented SBAR and successfully improved paraprofessional team communication … A Leadership Initiative to Improve Communication and Enhance Safety. … July 20, 2011
Implementing handoff communication.
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psnet.ahrq.gov/issue/targeted-communication-intervention-using-nursing-crew-resource-management-principles
August 12, 2015 - Study
Targeted communication intervention using nursing crew resource management … Targeted communication intervention using nursing crew resource management principles. … Targeted communication intervention using nursing crew resource management principles. … February 20, 2019
Failures in communication through documents and documentation across … January 9, 2011
Nurses' role in communication and patient safety.
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psnet.ahrq.gov/issue/gaps-pediatric-clinician-communication-and-opportunities-improvement
March 24, 2011 - Study
Gaps in pediatric clinician communication and opportunities for improvement … Gaps in pediatric clinician communication and opportunities for improvement. … Participants noted significant organizational and system barriers to effective communication, resulting … Gaps in pediatric clinician communication and opportunities for improvement. … February 15, 2011
Patient whiteboards as a communication tool in the hospital setting
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psnet.ahrq.gov/issue/health-literacy-and-communication-quality-health-care-organizations
November 26, 2014 - Study
Health literacy and communication quality in health care organizations. … Health literacy and communication quality in health care organizations. … multicenter study, patients with limited health literacy consistently reported dissatisfaction with the communication … Health literacy and communication quality in health care organizations. … January 3, 2017
Making it easier to do the right thing: a modern communication QI agenda
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psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
July 18, 2018 - Book/Report
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking … Citation Text:
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … Communication failures are known to contribute to medical errors. … Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores … URL
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Citation Text:
Malpractice Risks in Communication
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psnet.ahrq.gov/issue/closed-loop-communication-interprofessional-emergency-teams-cross-sectional-observation-study
September 24, 2016 - Study
Closed-loop communication in interprofessional emergency teams: a cross-sectional … observation study on the use of closed-loop communication among anesthesia personnel. … Closed-loop communication in interprofessional emergency teams: a cross-sectional observation study on … the use of closed-loop communication among anesthesia personnel. … the use of closed-loop communication among anesthesia personnel.
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-through-effective-communication-harnessing-power-information
March 10, 2011 - Commentary
Reducing diagnostic errors through effective communication: harnessing … Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology … This commentary explores potential communication breakdowns that contribute to diagnostic errors and … January 9, 2019
Dissecting communication barriers in healthcare: a path to enhancing … communication resiliency, reliability, and patient safety.
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psnet.ahrq.gov/issue/closing-loop-process-evaluation-inpatient-care-team-communication
March 09, 2019 - Study
Closing the loop: a process evaluation of inpatient care team communication … Closing the loop: a process evaluation of inpatient care team communication. … The study team found no statistically significant difference in communication-related disruptions in … patient care, but they did conclude that communication was more reliable when nurses carried mobile … Closing the loop: a process evaluation of inpatient care team communication.
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psnet.ahrq.gov/issue/theory-based-instrument-evaluate-team-communication-operating-room-balancing-measurement
June 23, 2010 - Commentary
A theory-based instrument to evaluate team communication in the operating … A theory-based instrument to evaluate team communication in the operating room: balancing measurement … This study describes the process of developing a tool to measure communication failures in the operating … A theory-based instrument to evaluate team communication in the operating room: balancing measurement … June 8, 2011
Silence, power and communication in the operating room.
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psnet.ahrq.gov/issue/intensive-care-units-communication-between-nurses-and-physicians-and-patients-outcomes
May 28, 2008 - Study
Intensive care units, communication between nurses and physicians, and patients … Intensive care units, communication between nurses and physicians, and patients' outcomes. … Although some relationship between communication and adverse events was documented, the relationship … Intensive care units, communication between nurses and physicians, and patients' outcomes. … December 19, 2018
Using incident reports to assess communication failures and patient
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psnet.ahrq.gov/issue/beyond-communication-role-standardized-protocols-changing-health-care-environment
October 12, 2011 - Study
Beyond communication: the role of standardized protocols in a changing health … Beyond communication: the role of standardized protocols in a changing health care environment. … This qualitative study found that implementation of the SBAR communication protocol had effects beyond … Beyond communication: the role of standardized protocols in a changing health care environment. … March 2, 2012
Implementing handoff communication.
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psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
October 19, 2022 - Study
ED handoffs: observed practices and communication errors. … ED handoffs: observed practices and communication errors. … ED handoffs: observed practices and communication errors. … September 4, 2019
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Related Resources
Closed-loop communication … in interprofessional emergency teams: a cross-sectional observation study on the use of closed-loop communication
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psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
August 28, 2013 - preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication … Structured communication tools are being used increasingly to prevent critical communication failures … While past studies have similarly demonstrated benefits from improved communication in the operating … room, this is the first to directly observe how briefings affect team communication. … April 6, 2011
Information transfer and communication in surgery: a systematic review.
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psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
March 03, 2011 - Study
Classic
Patterns of communication breakdowns resulting … Patterns of communication breakdowns resulting in injury to surgical patients. … The authors analyzed more than 80 communication breakdowns identified in a past review of surgical … Patterns of communication breakdowns resulting in injury to surgical patients. … May 27, 2009
Communication practices on 4 Harvard surgical services: a surgical safety
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psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
April 06, 2011 - Study
Classic
Communication failures in the operating room … Communication failures in the operating room: an observational classification of recurrent types and … This study used direct observation of 48 surgical procedures to characterize deficits in communication … Communication failures in the operating room: an observational classification of recurrent types and … June 8, 2011
Silence, power and communication in the operating room.
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psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals
February 05, 2014 - Study
Case outcomes in a communication-and-resolution program in New York hospitals … Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. … Communication-and-resolution programs underscore the importance of early disclosure of medical error … Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. … September 29, 2017
Challenges of implementing a communication-and-resolution program
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psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations
May 11, 2016 - Study
Challenges of implementing a communication-and-resolution program where multiple … Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate … Implementation of communication-and-resolution programs remains challenging despite the demonstrated … Using data obtained from sites implementing communication-and-resolution programs in Washington State … February 22, 2017
Ensuring successful implementation of communication-and-resolution