title: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.
abstract: BACKGROUND
  Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective.
  
  
  METHODS
  Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork.
  
  
  RESULTS
  Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes.
  
  
  CONCLUSIONS
  With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.
authors.affiliation: Danish Society for Patient Safety, Hvidovre Hospital, Kettegard Alle 30, DK-2650 Hvidovre, Denmark. louiseraboel@dadlnet.dk
authors.forename: Louise Isager
authors.initials: LI
authors.lastname: Rabøl
authors.forename: Mette Lehmann
authors.initials: ML
authors.lastname: Andersen
authors.forename: Doris
authors.initials: D
authors.lastname: Østergaard
authors.forename: Brian
authors.initials: B
authors.lastname: Bjørn
authors.forename: Beth
authors.initials: B
authors.lastname: Lilja
authors.forename: Torben
authors.initials: T
authors.lastname: Mogensen
mesh_terms: D003142:Communication; D003266:Continuity of Patient Care; D003299:Cooperative Behavior; D003718:Denmark; D006801:Humans; D033183:Interdisciplinary Communication; D010564:Personnel, Hospital