An Examination of the Role of Communication Problems in Preventable Medical Adverse Events

This exploratory, descriptive study examined 30 medical malpractice case files and 30 medical incident investigations to identify the prevalence of three barriers to effective communication among healthcare professionals. These cases were randomly selected from the files of the Office of the Air Force Surgeon General. Barriers included problems with encoding and decoding information, hierarchical structure of teams, and time pressures and workload. The results of this study indicated that communication errors were present in 76 percent of the cases examined. A total of 92 communication problems were noted. Verbal and written communication problems were equally distributed. Nurse and physician miscommunication was as common as physician-to-physician miscommunication. Eleven cases were noted as having hostile work environments. Only two cases involved problems with communication as the result of time pressures or workload. The study concludes a broad-based program that facilitates communication throughout healthcare facilities may help decrease medical errors. Suggestions for further research are given.

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