A recent study published in the May-June 2013 edition of Air Medical Journal analyzed a randomly selected group of quality assurance reports looking for communication errors. Quality assurance reports examined had been submitted in circumstances of issues, adverse events, or simply high risk activities (for example patient requiring intubation, or scene times exceeding 20 minutes)
Of 278 reports analysed, 58 (21%) were found to involve communication errors. Communication errors were categorised according to Clark’s Communication Level Hierarchy:
Level 1: CHANNEL – establishing a means of communication between people – e.g verbal communication, digital communication
Level 2: SIGNAL – the transmitted data, for example the sound in a verbal communication or the text in a digital communication
Level 3: INTENTION – the semantic meaning derived from the content within the data
Level 4: CONVERSATION – the joint activitiy that is understood between people communication (e.g. shared mental model)
Of 65 communication errors found (from 58 reports), less than a third had been identified by staff as communication errors. Communication errors occurred most commonly at level 1 (42/64) followed by level 4 (21/64). Level 2 and 3 failures were rare.
The most common communication issue was failure to communicate change in plan or status.
The authors concluded that current quality and safety reporting systems may lack the sensitivity to identify communication errors, and that improvements to the ontology of quality and safety reporting systems, user interfaces, and staff education on reporting of communication errors could enhance the safety of air medical transport services.
Read the full article HERE (secure area limited to ADHB staff only – ADHB has subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)
With thanks to Russell Clarke
Reblogged this on PHARM.