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| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| Patient safety | 2/10 | https://en.wikipedia.org/wiki/Patient_safety | reference | science, encyclopedia | 2026-05-05T04:26:13.019610+00:00 | kb-cron |
== Communication == Communication involves distributing relevant information across operational sites to ensure alignment. It also reduces administrative burden by using model-driven instructions, freeing up operational staff and easing procedural demands. This enables consistent execution with minimal but essential feedback, ensuring processes remain both efficient and controlled.
=== Effective and ineffective communication ===
The use of effective communication among patients and healthcare professionals is associated with a patient's health outcome. However, scientific patient safety research by Annegret Hannawa et al. has shown that ineffective communication can lead to patient harm. Communication regarding patient safety can be classified into two categories: the prevention of adverse events and the response to adverse events. Effective communication may help to prevent adverse events, whereas ineffective communication may contribute to their occurrence. If ineffective communication contributes to an adverse event, improved communication skills may be applied in response to achieve optimal outcomes for the patient's safety. There are different modes in which healthcare professionals can work to optimize the safety of patients which include both verbal and nonverbal communication, as well as the effective use of communication technologies. Methods of effective verbal and nonverbal communication include treating patients with respect and showing empathy, clearly communicating with patients in a way that best fits their needs, practicing active listening skills, demonstrating cultural sensitivity and awareness, and respecting the privacy and confidentiality rights of the patient. To use appropriate communication technology, healthcare professionals must choose which channel of communication is best suited to benefit the patient. Some channels are more likely to result in communication errors than others, such as communicating through telephone or email (missing nonverbal messages which are an important element of understanding the situation). It is also the responsibility of the provider to know the advantages and limitations of using electronic health records, as they do not convey all the information necessary to understand patient needs. If a health care professional is not practicing these skills, they are not being an effective communicator which may affect patient outcomes. The goal of a healthcare professional is to aid a patient in achieving their optimal health outcome, which entails that the patient's safety is not at risk. The practice of effective communication plays a crucial role in promoting and protecting patient safety.
=== Teamwork and communication === During complex situations, health professionals must communicate clearly and effectively. There are several techniques, tools, and strategies used to improve communication. Any team should have a clear purpose, and each member should be aware of their role and be involved accordingly. To increase the quality of communication between people involved, regular feedback should be provided. Strategies such as briefings allow the team to be set on their purpose and ensure that members not only share the goal but also the process they will follow to achieve it. Briefings reduce interruptions, prevent delays, and build stronger relationships, resulting in a strong patient safety environment. Debriefing is another useful strategy. Healthcare providers meet to discuss a situation, record what they learned, and discuss how it might be better handled. Closed loop communication is another important technique used to ensure that the message that was sent is received and interpreted by the receiver. SBAR is a structured system designed to help team members communicate about the patient in the most convenient form possible. Communication between healthcare professionals not only helps achieve the best results for the patient but also prevents any unseen incidents.
=== Safety culture ===
As is the case in other industries, when a mistake or error is made, people look for someone to blame. This tendency creates a blame culture where who is more important than why or how. A just culture, also sometimes known as no blame or no fault, seeks to understand the root causes of an incident rather than just who was involved. In health care, there is a move towards a patient safety culture. This applies the lessons learned from other industries, such as aviation, marine, and industrial, to a health care setting. When assessing and analyzing an incident, individuals involved are much more likely to be forthcoming with their own mistakes if they know that their job is not at risk. This allows a much more complete and clearer picture to be formed of the facts of an event. From there, root cause analysis can occur. There are often multiple causative factors involved in an adverse or near-miss event. It is only after all contributing factors have been identified that effective changes can be made that will prevent a similar incident from occurring.
=== Disclosure of an incident === After an adverse event occurs, each country has its own way of dealing with the incident. In Canada, a quality improvement review is primarily used. A quality improvement review is an evaluation that is completed after an adverse event occurs with the intention to both fix the problem as well as prevent it from happening again. The individual provinces and territories have laws on whether it is required to disclose the quality improvement review to the patient. Healthcare providers have an obligation to disclose any adverse event to their patients because of ethical and professional guidelines. If more providers participate in the quality improvement review, it can increase interdisciplinary collaboration and can sustain relationships between departments and staff. In the US, clinical peer review is used: uninvolved medical staff review the event and work toward preventing further incidents. The disclosure of adverse events is important in maintaining trust in the relationship between healthcare provider and patient. It is also important to learn how to avoid these mistakes in the future by conducting quality improvement reviews or clinical peer reviews. If the provider accurately handles the event and discloses it to the patient and their family, he/she can avoid getting punished, which includes lawsuits, fines, and suspension.
== Causes of healthcare error ==