title: Communication failures during clinical handovers lead to a poor patient outcome: Lessons from a case report.
abstract: In the emergency department, communication failures occur in clinical handover due to the urgent, changing and unpredictable nature of care provision. We present a case report of a female patient who was assaulted, and identify how various factors interacted to produce communication failures at multiple clinical handovers, leading to a poor patient outcome. Several handovers created many communication failures at diverse time points. The bedside medical handover produced misunderstandings during verbal exchange of information between emergency department consultants and junior doctors, and there was miscommunication involving plastic registrars. There was a failure in adequately informing the general practitioner and the patient relating to follow-up care after discharge. Deficiencies of communication occurred with conveying changes in an investigative report. Communication could be improved by dividing the conduct of handover in a quiet room and at the bedside, ensuring multiple sources of information are used and encouraging role-modelling behaviours for junior clinicians.
authors.affiliation: School of Nursing and Midwifery, Deakin University, Burwood, VIC, Australia; Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Manias
authors.affiliation: School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.
authors.forename: Fiona
authors.initials: F
authors.lastname: Geddes
authors.affiliation: School of Psychology, The University of Queensland, St Lucia, QLD, Australia.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Watson
authors.affiliation: School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Jones
authors.affiliation: School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.
authors.forename: Phillip
authors.initials: P
authors.lastname: Della
keywords: Clinical handover; adverse outcomes; communication; communication failure; emergency medicine