A Framework for the Analysis of Communication Errors in Health Care.

Abstract

Objectives: The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Methods: This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021. We also used Natural Language Processing to create a framework tool to classify the 9 types of communication errors using this taxonomy. Finally, analysis was done to identify affected clinical locations.

Results: We identified 9 types of communication failures that impacted clinical outcomes using the taxonomy code sheet developed. The top 3 errors were related to nonadherence to facility standard operating procedures (993, 37.6%), followed by written errors (e.g., unclear documentation or not using plain language) (587, 22.3%) and no communication (347, 13.2%). The remaining categories of communication types are electronic (253, 9.6%), verbal (205, 7.8%), hand-off (124, 4.7%), visual (76, 2.9%), listening (41, 1.6%), and nonverbal (12, 0.5%). A cognitive aide was developed to demonstrate the step-by-step method for using the framework tool to classify the communication errors.

Conclusions: The cognitive aide and the framework tool developed in this study can be used in any healthcare setting to identify and classify communication failures and mitigate potential risks contributing to safety events.