Abstract
Background:
Effective communication is essential for patient safety in complex pediatric healthcare environments. With the implementation of new interprofessional communication technologies such as secure messaging (SM), an updated understanding of communication breakdowns can inform targeted quality and safety interventions.
Objective:
We aimed to identify and characterize communication-related safety events occurring in inpatient pediatrics and to subsequently determine characteristics of interprofessional communication-related safety events specifically.
Methods:
A retrospective observational study was conducted using safety events reported to the internal hospital reporting system between March 2021 and March 2024 in a quaternary care pediatric hospital. Events were screened for communication involvement using keyword searches and expert reviewer classifications. Next, communication-related events were categorized using an exisiting communication failure mode categorization scheme. Disagreements between raters were resolved through consensus, and descriptive statistics were used to summarize findings. A sub-analysis of interprofessional communication failure types was also performed.
Results:
Of the 2184 confirmed communication-related events, Transfer/Handoff Communication Issues were the single most common type (22.0%, n = 481). The most common failure mode identified was error of purpose/cognition (38.9%, n = 850). Interprofessional communication events made up 58.3% of all communication-related events (n = 1274). Errors of audience and errors of purpose/cognition were more commonly identified in interprofessional safety events.
Conclusions:
A structured review process enabled the identification of communication events and failure modes, highlighting key areas for targeted safety interventions. Future efforts should focus on communication of shared mental models, reducing omission of information, and improving interprofessional communication models.
Keywords: health information technology, patient safety, interprofessional communication
Introduction:
The ability to communicate effectively, efficiently, and safely is paramount to the success of any hospital system.1,2 As pediatric hospital systems have become increasingly complex, communication within the hospital setting has had to adapt to meet the demand of increasing volume and interprofessional (here meaning between clinicians of different professions such as a physician and a nurse) care coordination required to take care of an evolving patient population.3
Modes of communication in the hospital are also changing, adding to complexity.4,5 Many hospitals - including our own health system - have added additional modes of communication such as secure messaging (SM) platforms to already existing modes such as in-person and telephone communication, thus changing the landscape of clinical communication.4 With these new modalities and the increased demand for streamlined interprofessional communication in the hospital setting comes the increased likelihood that differences in communication preferences and habits will lead to patient safety events and thus warrants an updated review on current communication failures leading to safety events.6,7
A robust body of literature has established the role of effective communication in preventing harm in the hospital.1,2,8,9 Despite significant attention to the issue, communication remains a top contributor to serious safety events in the hospital setting, suggesting that significant gaps still persist.7,10 These gaps are driven by a complex interplay of factors; Weller et al. describes psychological, organizational, and educational barriers to communication, while Umberfield et al., detail a communications-based framework to categorize different categories of communication-related safety events.11,12 Together, these findings underscore that communication failures are neither random nor uniform, but patterned, multidimensional, and amenable to systematic study. Understanding and classifying communication-related failures is therefore essential to developing targeted interventions that improve interprofessional communication and reduce harm in the hospital setting.
In this study, we sought to expand our understanding of communication-related safety events to pediatrics and interprofessional communication after the initiation of the new SM communication modality in our healthcare system. The primary objective of our study was to identify and categorize communication-related safety events in inpatient pediatrics. The secondary objective was to analyze interprofessional communication-related safety events and compare these events all other communication-related safety events as well as determine modalities of communications that contributed to communication events. Given the well-defined historical barriers to interprofessional communication, we hypothesized that interprofessional communication events would differ significantly from other non-interprofessional communication-related safety events in terms of communication failure modes.
Methods:
Setting
This retrospective observational study was performed within a single academic urban pediatric healthcare system that includes a 557-bed main hospital. This study was approved by our institutional review board.
Safety events at our institution are captured using a hospital safety reporting system. Any individual within the healthcare system can report a safety event using our web-based reporting system, Keeping All People Safe (KAPS) (RL Solutions, Toronto, Canada, https://rldatix.com/en-nam). A safety event in the context of this study was any submission in the KAPS system and does not necessarily indicate that harm reached the patient.
Identification of Communication-Related Safety Events
A structured query language (SQL) search was developed to identify communication-related safety events reported between March 2021 to March 2024 from the KAPS database. Events were included based on the use of communication-related terms in the text of the entry. Additionally, events were included if they had been previously identified by an institutional safety manager as related to communication. We also extracted necessary fields within the KAPS system for subsequent analysis (e.g. reporter role, location, event type).
Events that were extracted based on keyword were manually reviewed by the study team to confirm whether communication contributed to the event. We operationalized an event as communication-related if the event involved human-to-human interaction and any of the following were expressed: missing content, lack of information, misinformation, lack of shared understanding or awareness, language barrier, inability to reach the correct human, communication relating to patient handoff/admission/discharge/transfers, a desire to change communication modality, or feelings of excessive, redundant, inappropriate, or lack of communications. Events were excluded if they involved only technology to human interactions (i.e. a physiologic alarm did not reach the bedside nurse), referred to patients not currently admitted to the hospital at the time of the report, or described documentation or orders without interpersonal communication.
Approximately 10% of events were double coded to assess inter-rater reliability (IRR) for communication failure using Cohen’s kappa. The team met iteratively to resolve discrepancies until achieving a kappa > 0.8. Following this, the remaining events were single-coded, with regular group discussions held for any unclear cases.
Categorization of Failure Mode in Communication-Related Safety Events
Following identification of communication-related safety events, we applied an existing categorical framework from Umberfield et al. to further classify the communication event into one of six categories of communication failures - errors of content, audience, purpose/cognition, occasion, professionalism, and omission (see Table 1 for operational definitions).12 Approximately 10% of events were double coded to assess inter-rater reliability using Cohen’s kappa, with discrepancies resolved through iterative discussion until kappa > 0.8 was achieved. The remaining events were single-coded, with group review of ambiguous cases. Each event was also coded for interprofessional communication (defined as interaction between patient care providers of different professions (e.g., nurse to doctor, doctor to respiratory therapist, but not physician to physician or nurse to nurse) and communication modalities involved (e.g., in-person, phone, secure messaging). Regular meetings were held to discuss questions that arose. Events were excluded if, after group review, they were found to be duplicate reports of the same safety event submitted by different providers.
Table 1:
Operational Definitions of Communication-Related Events from Structured Review
| Umberfield Communication Failure Mode17 | Operational Definition | Example * |
|---|---|---|
| Error of Omission | No communication occurred or missing content, lack of communication | No sign out provided prior to patient arrival on unit |
| Error of Purpose/Cognition | Unresolved goals, implicit or explicit, of the communication event, lack of shared mental model, or a knowledge gap | Report citing “poor communication” about patient status |
| Error of Content | Communication events for which information was inaccurate | Incorrect Medical Record Number (MRN) |
| Error of Audience | Events where the appropriate individuals were not participating or were unable to be reached | Unable to reach provider when needed |
| Error of Occasion | Inappropriate physical or temporal situation of the exchange | Provider sent a secure message about a patient that would have been more appropriate as a phone call |
| Error of Professionalism | Communication event where one or more party engaged in unprofessional activity compromising safety | Inappropriate communication in presence of family |
Examples are reflective of the types of events classified under each Failure Mode but are not a reference to an actual event
Data Analysis:
Descriptive statistics were used to summarize count and percentage of individual characteristics of safety events including submitter type, communication failure type, original KAPS submission category as determined by submitter (i.e. Transfer/Handoff Issue, Medication Error), and communication modality. Differences within categorial variables across interprofessional and non-interprofessional communication were assessed by Pearson’s chi square test. Standardized mean difference (SMD) and corresponding 95% confidence intervals (CI) were also calculated. A p-value < 0.05 was deemed statistically significant.
A post-hoc analysis was performed to assess differences in the proportion of each communication failure mode between interprofessional and non-interprofessional safety events (here meaning any event that was either between two people from the same profession or the interprofessional nature of the event could not be determined). Two-sample test for equality of proportions with continuity correction was utilized. P-values were adjusted for multiple comparisons as previously described.13 Differences in proportions were deemed statistically significant at adjusted p< 0.05.
Statistical analysis was performed using R version 4.4.0.14
Results:
A total of 67,188 safety events were reported within the KAPS system during the period of interest. After SQL query, 2421 events were flagged as potentially having contributions from communication (Figure 1). After manual review, 1522 were determined to be communication related. Additionally, 686 events had an existing label of being communication-related, and so were automatically included in the failure mode analysis. After removing 24 duplicate events, 2184 events were ultimately included in the communication failure modes analysis.
Figure 1:
Consort Diagram of Communication-Related Safety Event Identification and Classification
Communication-Related Safety Event Analysis:
The primary results of the communication-related safety event analysis are presented in Table 2. Nurses were the most frequent overall reporters of communication-related safety events (66.3%, n = 1448), followed by physicians (15.7%, n = 342) and advanced practice providers (6.2%, n = 135). The most frequently reported event types from available KAPS categories were Transfer/Handoff Communication Issues (22.0%, n = 481) followed by Delay/Lack of Response to Patient Condition (4.9%, n = 107), with the remainder of the events having less than 4.0% prevalence each among all submission types.
Table 2:
Descriptive Comparison of Interprofessional and Non-Interprofessional Communication-Related Safety Events
| 95% CI3 | ||||||
|---|---|---|---|---|---|---|
| Submitter | <0.001 | 0.19 | 0.10, 0.27 | |||
| Physician | 342 (15.7%) | 187 (14.7%) | 155 (17.0%) | |||
| Advanced Practice Provider | 135 (6.2%) | 87 (6.8%) | 48 (5.3%) | |||
| Nurse | 1,448 (66.3%) | 821 (64.4%) | 627 (68.9%) | |||
| Other | 259 (11.9%) | 179 (14.1%) | 80 (8.8%) | |||
| Communication Failure Type 17 | <0.001 | 0.43 | 0.34, 0.52 | |||
| Errors of Audience | 250 (11.5%) | 198 (15.5%) | 52 (5.7%) | |||
| Errors of Content | 193 (8.9%) | 93 (7.3%) | 100 (11.0%) | |||
| Errors of Occasion | 141 (6.5%) | 93 (7.3%) | 48 (5.3%) | |||
| Errors of Omission | 687 (31.5%) | 329 (25.8%) | 358 (39.3%) | |||
| Errors of Professionalism | 63 (2.9%) | 36 (2.8%) | 27 (3.0%) | |||
| Errors of Purpose/Cognition | 850 (38.9%) | 525 (41.2%) | 325 (35.7%) | |||
| KAPS Category | <0.001 | 0.33 | 0.24, 0.41 | |||
| Transfer/Handoff | 481 (22.0%) | 214 (16.8%) | 267 (29.3%) | |||
| Delay/Lack of Response to Patient Condition | 107 (4.9%) | 80 (6.3%) | 27 (3.0%) | |||
| Other | 1,596 (73.1%) | 980 (76.9%) | 616 (68.0%) | |||
| Communication Modality | <0.001 | 0.59 | 0.51, 0.68 | |||
| In Person | 216 (9.9%) | 127 (10.0%) | 89 (9.8%) | |||
| Multimodal | 437 (20.0%) | 342 (26.8%) | 95 (10.4%) | |||
| No Communication | 625 (28.6%) | 269 (21.1%) | 356 (39.1%) | |||
| Phone | 222 (10.2%) | 162 (12.7%) | 60 (6.6%) | |||
| Secure Chat | 126 (5.8%) | 87 (6.8%) | 39 (4.3%) | |||
| Unable to Determine | 558 (25.6%) | 287 (22.5%) | 271 (29.8%) |
n (%)
Pearson’s Chi-squared test
Standardized Mean Difference
Abbreviation: CI = Confidence Interval
The most common failure mode identified in our analysis was error of purpose/cognition (38.9%, n = 850) followed by errors of omission (31.5%, n = 687). Errors of audience (11.5%, n = 250), errors of content (8.8%, n = 193), errors of occasion (6.5%, n = 141), and errors of professionalism (2.9%, n = 63) were reported less frequently.
In terms of communication modality identified, multi-modal communication (20.0%, n = 437), communication over the phone (10.2%, n = 222), and in-person communication (9.9%, n = 216) were most common. We were not able to determine the modalities used in 25.6% (n = 558) of events based on reported information. An additional 28.6%, (n=625) did not have a communication modality identified as the event was characterized by lack of communication.
Of the 2184 events reviewed, 1274 events (58.3%) were determined to be interprofessional in nature (communication between providers of different professions), while 910 (41.7%) were deemed non-interprofessional. Mode of communication differed across interprofessional and non-interprofessional communication-related events (p< 0.001); the most common communication modality for interprofessional safety events was multi-modal (26.8%, n = 342), as opposed to “no communication” in the non-interprofessional subgroup (39.1%, n = 356). KAPS category also differed between interprofessional and non-interprofessional events (p < 0.001), with a higher percentage of transfer/handoff events reported among non-interprofessional events (29.3%, n = 267) compared to interprofessional events (16.8%, n = 214). Nurses were the most frequent submitter for both interprofessional (64.4%, n= 821) and non-interprofessional (68.9%, n = 627) communication safety events.
While the distribution of each variable (submitter, communication failure type, KAPS category, communication modality) differed significantly by safety event type (interprofessional v. non-interprofessional; p’s < 0.001), standardized mean difference was largest for communication modality (0.59; 95% CI: 0.51 – 0.68), followed by communication failure type (0.43; 95% CI: 0.34–0.52), KAPS category (0.33; 95% CI: 0.24–0.41), and submitter role (0.19; 95% CI: 0.10–0.27),
Communication Failure Mode Sub-Analysis
When assessing differences in the proportion of each communication failure mode between interprofessional and non-interprofessional safety events, errors of omission (p < 0.001), errors of audience (p < 0.001), errors of content (p = 0.007), and errors of purpose/cognition (p = 0.016) were all statistically significantly different following adjustment for multiple comparisons (Table 3). Errors of audience and errors of purpose/cognition were more commonly reported in interprofessional safety events, while errors of content and errors of omission were more commonly reported in non-interprofessional safety events.
Table 3:
Communication Failure Type Sub-Analysis
| P-value3 | ||||||
|---|---|---|---|---|---|---|
| Errors of Audience | 250 (11.5%) | 198 (15.5%) | 52 (5.7%) | 9.8% | 7.2%, 12.0% | < 0.001 |
| Errors of Content | 193 (8.9%) | 93 (7.3%) | 100 (11.0%) | −3.7% | −6.3%, −1.1% | 0.007 |
| Errors of Occasion | 141 (6.5%) | 93 (7.3%) | 48 (5.3%) | 2.0% | −0.1%, 4.2% | 0.08 |
| Errors of Omission | 687 (31.5%) | 329 (25.8%) | 358 (39.3%) | −14.0% | −18%, −9.4% | < 0.001 |
| Errors of Professionalism | 63 (2.9%) | 36 (2.8%) | 27 (3.0%) | −0.14% | −1.7%, 1.4% | > 0.9 |
| Errors of Purpose/Cognition | 850 (38.9%) | 525 (41.2%) | 325 (35.7%) | 5.5% | 1.3%, 9.7% | 0.02 |
n (%)
Standardized Mean Difference
2-sample test for equality of proportions with continuity correction
Abbreviation: CI = Confidence Interval
Discussion:
This single-center retrospective cohort study identified and classified communication-related safety events from the internal safety reporting system, demonstrating that most were errors of purpose or cognition. Additionally, we found that communication failure modes differed significantly between non-interprofessional and interprofessional safety events. These findings underscore the complexity of communication in healthcare and suggest challenges in aligning communication between different professional roles and responsibilities.
Our findings align with studies showing that fragmented communication -especially during handoffs - contribute substantially to increased reporting of perceived safety events.15 The most common communication-related KAPS category in our analysis was Handoff/Transition of Care (although only 22%), a long-cited area of high risk for patient safety events.16,17 Because inpatient handoffs do not always involve the interprofessional team, it was not surprising that non-interprofessional events represented a higher percentage of handoff events. However, while interprofessional handoffs are uncommon, they may represent an area of opportunity to increase awareness of patients moving through the system and create increased situational awareness for clinicians across the inpatient space.18
Our results underscore that interprofessional communication involves unique challenges, such as unclear targeting of messages or misaligned understanding of clinical goals.19 In our analysis, errors of audience - where communication is misdirected or fails to reach the appropriate recipient - were significantly more common in interprofessional events than non-interprofessional events. This highlights the need for defined communication roles, clear escalation paths, and reliable routing systems, particularly during high-stakes processes such as transitions of care.
We believe this is one of the first explorations of safety event data in the context of SM platform introduction. Given the recent literature around the increasing message burden that SM has had on healthcare teams, it was surprising to find such a small proportion of safety events represented by this emerging and poorly understood communication modality.12,14 Within this context, we also expected errors of occasion (incorrect communication modality used) to represent a higher proportion than what was found (141 events, 6.5%), given that teams are still adapting best practices to use SM within clinical scenarios. It is possible that our safety reporting systems have not yet aligned with these new technologies. While our safety reporting system did have discrete methods to capture secure chat issues, many communication events appear to under-utilize those tools for capture or the event reporters did not identify secure chat as a significant contributor in the event reported. This is reflective of prior research demonstrating that safety reporters may under-recognize health technology safety issues and attribute safety concerns to things like culture, human error or factors other than the design of the technologies themselves.20 Alternatively, a culture shift may be needed towards classifying these communication-related issues as reportable safety events, which could help to identify opportunities for improvement in the system. Our study underscores the importance of reviewing safety data and reporting systems in the context of new implementation of communication technologies.
Finally, in considering all safety events reported, the events classified as explicitly related to communication represent a relatively small proportion of all events (2184 events, 3.3%). This differs from extant literature suggesting that communication contributes to a large proportion of safety events, and reinforces the fact that while communication is anecdotally a large driver of safety events, it remains challenging to capture in safety event reporting.2,21 Further elucidation of communication in safety event reporting may be helpful to identify communication-related safety events more easily. Improved classification of safety events in reporting systems could enhance understanding of barriers and potential areas for action. For example, Errors of Audience may signal the need for clearer role delineation, whereas Errors of Omission signal breakdowns in initiation of communication, which may indicate issues such as lapses in psychological safety or technology failures.
Limitations:
There are several notable limitations to our study. First, although safety event databases capture important perspectives from within healthcare systems, they are an imperfect way to identify all safety-related issues, as they are dependent on clinician report. Reported safety events may therefore represent a biased sub-section of actual safety events occurring in a hospital system and should therefore not be extrapolated to apply to all health systems or all problems within a particular health system. In addition, we did not evaluate whether the reported safety event led to an actual error in care or harm to the patient. This study was also conducted within a single health system, and local safety initiatives and culture may impact generalizability of reporting.
The amount of detail provided in the safety event report likely impacted our ability to classify some events accurately. Although longer safety reports retain more details of the event in question, they were often more difficult to glean actionable items from given the complexity of the situation described and introduce the opportunity to generalize findings.
Finally, the fact that many of our team members work clinically in different roles could also have biased some of our classification schema. As our team reviewed safety events that were disagreed upon, there were several instances where individuals with either nursing or physician experience extrapolated safety event classification based on known expertise and the fact that processes within each of these domains may be related to communication although not specifically stated in a communication event.
Conclusions and Suggested Next Steps:
Communication within the hospital setting continues to be a challenging problem for operational and safety leaders to tackle, with communication-related safety events remaining difficult to recognize and respond to within safety reporting systems. Although not currently represented proportionately in safety events reports, new communication modalities such as SM deserve ongoing attention for safety leaders as they become more frequently utilized and have the possibility to affect safety culture. Further investigation into communication failure modes represents an opportunity to target interventions that reduce high-stakes communication failures.
To improve clinician-to-clinician communication and reduce the risk of communication-related patient safety events, our findings suggest that interventions should focus on efforts to enhance shared mental models (particularly among interprofessional teams) and to increase the amount of high value communication. Qualitative methods may be useful to better understand the conditions driving failure modes. Interventions such as interprofessional handoffs, standardized communication templates, and AI EHR summaries could be tested to support shared mental models and improved communication.
Acknowledgments:
The authors thank Michael A. Posencheg, MD, for his support of this work and review of the manuscript.
Funding source:
Brianna Reed, Amina Khan, Brooke Luo, Alexis Tomlinson, and Halley Ruppel received funding support from a Patient Safety Learning Lab grant from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services under grant number R18HS029473. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.
Footnotes
Financial Disclosure Statement: The authors have no financial disclosures to report.
Conflict of Interest Statement: The authors have no conflicts of interest to disclose.
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