Poor Communication Still a Major Patient Safety Concern

As I look at ECRI’s top ten patient safety concerns of 2023 I am struck by a common theme: lack of communication. With thirty plus years as a registered nurse, most recently in care coordination and population health, I still see poor communication between providers as a major patient safety concern, despite the investment in technology for improving communication. Healthcare communication is complex and multifaceted, involving multiple providers, patients, and caregivers across different care settings.

The use of technology and standard protocols can certainly help to improve communication, but there are other factors that can impede effective communication. One factor that can contribute to poor communication is the lack of standardized protocols. In healthcare there are often variations in terminology and processes used by different providers and organizations. This can lead to confusion and misunderstandings, especially when communicating critical information. Standardized protocols can help to ensure that everyone involved in patient care is using the same terminology and following the same processes, which would help improve communication and reduce the likelihood of errors.

However, the implementation of standardized protocols can also be challenging particularly in a complex dynamic environment like healthcare. It can be difficult to get everyone on board and to ensure that everyone consistently follows the protocols. Additionally, the use of technology can create new communication challenges, such as information overload or difficulties in navigating complex electronic medical records systems. Overall, while technology and standardized protocols are important tools for improving communication and healthcare, they are not the sole solution. Improving communication requires a multifaceted approach that includes improved communication technology, but also fostering a culture of collaboration and open communication, providing education and training to healthcare providers, and continuously evaluating and improving communication processes.

ECRI Patient Safety Concern #3: Clinician Needs in Times of Uncertainty Surrounding Maternal Fetal Medicine

The following strategies can help healthcare organizations support clinicians and address changes in how maternal fetal medicine is delivered:

Identify Areas of Uncertainty — This can include changes in treatment protocols, recent technologies, and emerging research. By understanding these areas of uncertainty healthcare organizations can develop strategies to support clinicians and making safe and effective clinical decisions.

Implement Guidelines, Algorithms, and Protocols — Solutions like these that support effective and safe clinical decision making can help clinicians navigate areas of uncertainty. Provide training and education for clinicians to help them stay up to date with the latest research and best practices in maternal fetal medicine.

Build a Culture of Continuous Improvement — A focus on improvement in maternal fetal medicine delivery may include regular review and evaluation of clinical processes and outcomes, as well as feedback from patients and families. By continuously evaluating and improving their practices, healthcare organizations can help to ensure that clinicians are delivering safe and effective care to high-risk pregnancy patients.

ECRI Patient Safety Concern #6 (Consequences of Poor Care Coordination for Patients with Complex Medical Conditions) and #8 (Medication errors resulting from Inaccurate Patient Medication Lists)

Optimize multidisciplinary teams to help ensure that providers work collaboratively alongside each other toward a common goal: keeping the patient and their family as central members of the team for the prevention and treatment of medical conditions. I have seen firsthand how a multidisciplinary team can become siloed without an intentional effort to work collaboratively. This means regular team meetings or huddles with the patient, patient representative, or guardian; specific responsibilities for team members; standardized communication tools; ability to share information across multidisciplinary teams; and involvement of community-based services. Having multiple specialists and providers on a patient’s care team is important. However, it may also increase care complexity and the risk for medication errors due to miscommunications and having more than one provider prescribing medications. Handoff communication is essential at each step of the process.

Handoff communication involves the transfer of patient information, including medication information, between healthcare providers during transitions of care. This communication should be standardized, concise, and timely, and should include all relevant information about a patient’s medical history, current condition, and medication regime. For patients with complex medical needs, accurate medication reconciliation is essential to avoid adverse events, medication errors, and potentially harmful drug interactions. If important medication information is not accurately communicated during handoffs, it can lead to medication errors and negatively impact patient outcomes.

Healthcare teams should have effective communication strategies and protocols in place to ensure that medication information is accurately communicated between providers. This may involve the use of electronic health records, standardized handoff tools, and communication training for healthcare providers. Healthcare teams must prioritize effective communication to improve patient outcomes and to avoid medication errors.

About this Commentary

Each month, we select an article to feature in ProVisions, ProAssurance's agent magazine. ProAssurance thought leaders comment on the article, adding additional insight as to how the topic impacts their work in the insurance industry.

Joanne Simmons, Senior Risk Management Consultant, provided the above as part of our April 2023 ProVisions issue. Agents can see the full issue in context on our agent website.


ProAssurance Risk Management is offering a national online seminar that will help equip physicians and their teams with tools and strategies to enhance team communication and prevent patient harm. Participants will learn evidence-based techniques to enhance leadership, increase situational awareness, and improve team interactions. In addition, we are developing an ob-gyn bundle that will include resources with skills check lists, sample informed consents, and a variety of templates a practice can edit to fit their specific needs.