From Risk to Reliability: Evidence-Based Communication Saves Lives

As healthcare professionals, we know that communication is at the heart of everything we do. Whether it’s communicating with patients, families, or our colleagues, the way we exchange information can be the difference between life and death. But what happens when communication fails, and why are the stakes so much higher in healthcare compared to other industries?

How communication failures impact patient safety

Unlike other professions, in healthcare, poor communication doesn’t just result in inefficiency or misunderstanding; it directly impacts patient safety. 

1. Communication as a leading factor in adverse outcomes

   Communication failures are a leading cause of medical errors and adverse outcomes in healthcare. According to The Joint Commission (TJC), communication breakdowns contribute to over 70% of sentinel events (i.e., unexpected events involving death or serious injury) in hospitals. These include medication errors, delayed diagnoses, and surgical complications. Furthermore, a report by the Institute of Medicine (now known as the National Academy of Medicine) estimates that medical errors are the third leading cause of death in the United States, after heart disease and cancer, accounting for approximately 250,000 deaths per year.

2. Communication failures during handoffs 

   Poor handoff communication, whether during shift changes or transfers of care, continues to be a significant issue in preventing adverse events. The Joint Commission (2020) found that 80% of serious medical errors involve miscommunication during patient handoffs, which can result in delayed treatments, missed diagnoses, or even surgical complications. ⁠ ⁠A more recent study published in JAMA Surgery (2021) further emphasized this issue, revealing that nearly 40% of adverse events in surgery were attributed to handoff communication failures between surgical teams, particularly in complex surgeries. The study highlighted how gaps in communication between teams, including failure to relay critical patient information or confirm surgical plans, can lead to severe patient harm.

3. Communication and medication errors

   Medication errors continue to be a leading cause of patient harm, with poor communication being a primary contributing factor (Howick et al, 2024). According to Rodziewicz and colleagues (2024), the risk of medical errors may be significantly reduced by using standardized communication systems, encouraging error reporting, electronic data and order entry, medication reconciliations, and error prevention clinical care protocols.

4. The role of nurse-physician communication in adverse events 

   A study published in the Journal of Patient Safety (2022) demonstrated that miscommunication between nurses and physicians leads to diagnostic delays and treatment errors. Hospitals that implemented regular team huddles and communication training showed a 28% reduction in adverse patient outcomes.

3 Evidence-Based Communication Tools for Safer Patient Care

Integrating these principles into our toolkits can create a safer, more efficient healthcare environment by reducing risks and improving care quality. Below, we explore three evidence-based communication tools shown to enhance patient safety, care quality, and team collaboration. ⁠ ⁠3 evidence-based communication tools: ⁠1. STAR ⁠2. TeamSTEPPS ⁠3. ARCC

Managing distractions and preventing errors: stop, think, act, review

⁠In healthcare, we often find ourselves rushing from one task to another, juggling multiple responsibilities at once. The nature of our environment means that unanticipated problems are always arising, for example, a newly admitted patient developing respiratory distress or critical lab results (e.g., a potassium level of 6.1 or hemoglobin of 7.4) that require immediate attention. In these high-pressure situations, how do we ensure we don’t make errors? ⁠ ⁠The STAR tool (Stop, Think, Act, Review) is a high-reliability organization (HRO) tool designed to help manage distractions, fatigue, and stress, ultimately reducing the likelihood of errors. In high-reliability environments like healthcare and aviation, where mistakes can have severe consequences (e.g., sentinel events or fatalities), the STAR tool offers a simple yet effective way to promote self-checking habits and reinforce a culture of safety. By consistently using the tool, you build the habit of pausing, thinking, and focusing on the task at hand, helping to reduce errors, particularly in high-stakes, fast-paced environments.

STAR

Non-Clinical Example: ⁠Imagine this scenario: After working a 10-hour shift, you need a quick snack to get you through the rest of the day. You're giving a report and then head straight to the vending machine. Chocolate! You eye the options and decide on Peanut M&Ms. But before you make your selection, what do you do?

Stop: Pause for a moment to focus on your decision. ⁠ ⁠Think: Consider your choice and ensure you’re getting exactly what you want.

Act: Select the numbers for your Peanut M&Ms.

Review: Double-check to confirm you’re not accidentally choosing Raisins instead.

Even in day-to-day moments like this, you’re practicing the STAR tool, taking deliberate actions to avoid errors when fatigue sets in. This simple process of stopping and reviewing before acting is a habit you can carry into more critical tasks, ensuring that you reduce errors when it matters most.

Escalating concerns: trust your gut and take action 

As healthcare professionals, we often have a gut feeling or notice changes in a patient's condition that signify early warning signs or deterioration. It’s essential to act on these instincts and escalate concerns promptly. When you sense a problem on the horizon, don’t wait; be proactive and speak up.

The importance of escalating safety concerns cannot be overstated. Remember, "What you permit, you promote." Failing to address potential risks only increases the likelihood of preventable harm. 

The TeamSTEPPS: CUS tool provides a simple, effective structure for raising your concerns in a way that everyone understands and responds to.

TeamSTEPPS: CUS

Commit to speaking up and listening when there’s a concern

The ARCC tool is a powerful communication strategy used in high-reliability organizations to respectfully and effectively escalate safety concerns.  It is particularly useful when perceived authority differences might discourage people from speaking up. This structured approach empowers individuals to voice concerns, ensuring they are heard and addressed, even in situations where someone may feel hesitant or intimidated to speak up.

ARCC

💡Protips: Always use a calm and respectful tone. Remaining professional is essential. Start with the lightest touch: Ask a question. If the issue is resolved at that point, there’s no need to escalate further; however, if the problem persists, continue through the steps. Request a change, convey a concern, and, if necessary, go up the chain of command until the issue is addressed.

Graphic Source: Nomad Health

Safer Care Starts Here: Embrace Evidence-Based Communication

When communication in healthcare fails, the consequences are severe. But when communication is clear, open, and structured, the benefits are profound: ⁠better patient outcomes, higher quality of care, fewer errors, and improved teamwork.

As healthcare professionals, we need to prioritize effective communication every day, not just for patient safety but for our own well-being and the success of the healthcare system as a whole.

By embracing evidence-based communication strategies, we can make healthcare safer, more efficient, and ultimately more compassionate for the patients we serve.

References

• Allen, C. G., et al. (2022). The impact of nurse-physician communication on patient safety and clinical outcomes: A systematic review. 
• Howick J, Bennett-Weston A, Solomon J, Nockels K, Bostock J, Keshtkar L. How does communication affect patient safety? Protocol for a systematic review and logic model.  BMJ Open. 2024 May 27;14(5):e085312. doi: 10.1136/bmjopen-2024-085312. PMID: 38802275; PMCID: PMC11131125.
• Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the U.S. BMJ, 353, i2139.
• O'Neill, L., Godden, B., & Lee, S. (2021). Handoffs in surgery: Improving communication in complex clinical settings. JAMA Surgery, 156(4), 381-387.
• Rodziewicz TL, Houseman B, Vaqar S, et al. Medical Error Reduction and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/.
• The Joint Commission (2015). Sentinel Event Data: Root Causes Analysis Reports. The Joint Commission.
• The Joint Commission (2012).  Improving Hand-Off Communication. Sentinel Event Alert, Issue 58.
• Tool: STAR. Content last reviewed July 2024. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps-program/curriculum/situation/tools/star.html.