Communication between clinicians forms the central point of handovers and is a known point of medicolegal risk. Dr Sarah Coope, Senior Medical Educator at Medical Protection, looks at the gaps in information, misunderstandings and assumptions that can increase the risk of errors, conflict and complaints
While we can’t have complete control over our patients’ illness and disease progression, or the way they respond to interventions, we can take steps to ensure there is a strong bridge of communication to support effective continuity of care for the patient, give protection against adverse events and reduce medicolegal risk.
Imagine you are between appointments on a busy Friday afternoon. Your phone rings and shows your colleague’s number on the screen, so you answer. She asks you if you mind covering a home visit she had planned for a patient well known to her at the end of the surgery as she needs to go and visit her elderly mother who has had a fall.
How do you respond? Most of us would agree to do this, knowing that these arrangements often need to be reciprocated. However, how strong is that bridge as the patient moves across to your care and responsibility, albeit temporarily?
No doubt you would usually ask more questions before ending the call. You would seek to find out more about the patient’s background and what important information your colleague can give you regarding the reason for the home visit and any management plans she had in mind.
For much of the time, despite any weakness in the communication bridge at the point of transition, these situations pass uneventfully.
However, there are inevitably occasions when this is not the case. You accept a handover from a colleague, either a cover arrangement such as this or agree to give a second opinion, arrange an admission or referral of your patient, and then things go wrong as they move between care providers.
Sometimes this is due to complications arising that you couldn’t have foreseen, but other times analysis of adverse outcomes indicates that communication failure between colleagues around the time of the handover is frequently the root causei,ii. For example, a significant underlying condition isn’t mentioned, a drug is missed off their referral letter or a key abnormal observation or result isn’t alluded to. And not having this information may lead to poor decision-making or sub-optimal management.
If the communication bridge has weak structure and gaps, the care of the patient can easily fall through.
Often several health professionals are involved in a typical patient’s care journey, eg from the GP to consultant specialist, radiologist, theatre and ward staff, pharmacist, physiotherapist and back to the GP. The more people who are involved, the more bridges the patient is crossing, and the greater the chance of there being miscommunication and errors.
Many conversations about patient care with our colleagues take place over the phone rather than in-person. Remote communication can exacerbate the risks further, primarily due to a lack of visual and non-verbal information in the interaction. The oft-stated phrase “words make up only 7% of your message” resonates here. Aside from the content of your spoken words, the other 93% of the communication comes from the style of delivery. This includes the speaker’s body language, tone of voice and attitude which all convey crucial meaning, however much of this is missing on the telephone. And what is said, is therefore more open to misinterpretation. So particularly for complex cases, discussing the patient over a video call might be a less risky option to consider if face-to-face isn’t possible.
Common causes of weak links and gaps
What stops us from transmitting key information when referring a patient, or ensuring that we’ve received all the facts we need to know when accepting a handover remotely?
What jeopardises the strength in these telecommunication bridges, that can affect safe transition of patient care? There are in fact a range of factors affecting either the quality of the interaction or of the information.
Those affecting the quality of the interaction include:
- Barriers in access to, availability and approachability of colleagues
- Unstable connection and signal if using a mobile device
- High level of external interruptions, distractions and time pressure
- Existing dysfunctional relationships and lack of trust
- Reluctance to take responsibility
These are not always easy to eliminate or resolve but it is helpful to be aware of them and compensate where possible by consciously strengthening the factors that you can address.
Those factors affecting the quality of the information obtained include:
- Inadequate preparation before the call
- Lack of relevant facts about the patient’s situation, current status or background
- Missing detail about the care received so far
- Unclear message, agenda or request
- Lack of confidentiality or privacy when taking the call
- Not building a positive connection or rapport
- Ignoring verbal cues
- Abrupt or dismissive manner
- Interrupting or talking over
- Assumptions about a colleague’s level of knowledge and skill
- Not clarifying areas that are ambiguous
- Not speaking up or challenging potentially sub-optimal decisions
Strengthening the communication of the transition conversation
All of these potential weak links are important, but the key thing to focus on is ensuring that adequate, relevant information is included in a handover.
A framework can be helpful to have in the forefront of your mind, to aid preparation before making a call, or during accepting a patient. You may already be familiar with the SBAR model (see table below), widely used in clinical settings although initially developed by Dr Michael Leonard for the US Military to assist with safe communication on nuclear submarines.
S – situation
• Identify yourself and the site/unit you are calling from
• Identify the patient by name and the reason for your communication
• Describe your concern
B – background
• Give the patient’s reason for admission
• Explain significant medical history
• Inform the receiver of the information of the patient’s background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results
A – assessment
• Vital signs
• Trajectory of the patient’s condition
• Clinical impressions, concerns
You need to think critically when informing the receiver of your assessment of the situation. This means you have considered the possible underlying reason for your patient’s condition. Not only have you reviewed your findings from your assessment but you have also consolidated these with other objective indicators, such as laboratory results.
R – recommendation
That is, what would you like to happen by the end of the conversation. Any advice that is given on the phone needs to be repeated back to ensure accuracy
• Explain what you need – be specific about request and time frame
• Make suggestions
• Clarify expectations. Have a clear agenda, request or purpose – include concerns about what’s likely to happen
So, how strong are your remote interactions with colleagues in these situations? Next time you pick up the phone to accept or make a patient handover, remember the bridge analogy and aim to build a safe, solid structure into your communication.
By reflecting on this, and making changes to the way that you present or receive vital information about a patient, you can fill in the gaps, strengthen the connection, increase the chance of a smooth transition of care and mitigate the associated medicolegal risk.
Overcoming risky remote interactions with colleagues forms part of Medical Protection’s new four-part series of webinars on telemedicine. Medical Protection members can find out more about these webinars via our e-learning platform, Prism
iJoint Commission on Accreditation of Healthcare Organizations, The Joint Commission guide to improving staff communication, Oakbrook Terrace, IL: Joint Commission Resources (2005)
iiBeckman HB, Markakis et al, The doctor-patient relationship and malpractice: Lessons from plaintiff depositions, Archives of Internal Medicine 154: 1365-1370 (1994)