Communication skills and error in the intensive care unitTom W. Readera, Rhona Flina and Brian H. Cuthbertsonb

Purpo

Poor comm

freque

There

comm

agains

comm

intens

Recen

Error s

comm

Interve

care u

events

effecti

techni

comm

betwe

more c

tools b

Summ

Critica

comm

reduci

trainin

intens

unders

import

medic

Keyw

comm

teamw

Curr Opin C 2007 W

aSchool ofbHealth Seand Aberde

CorrespondKings ColleTel: +44 1

Current O

Abbreviat

ICU inte

2007 W1070-5295

darctlyblanighlitiy wu

erscalnuclexhasr inWuctudeeseenrlystrinsher b, ticatntrchCUm

mnsntsptnalheedg aInenntscatme rent while receiving intensive care, ICU research

732has attempted to ascertain common causes of error. Inis now a strong emphasis on identifying the

unication skills that can contribute to, or protect

t, preventable medical errors. This review considers

unication research recently conducted in the

ive care unit and other acute domains.

t findings

tudies in the intensive care unit have shown good

unication to be crucial for ensuring patient safety.

ntions to improve communication in the intensive

nit have resulted in reduced reports of adverse

, and simulated emergency scenarios have shown

ve communication to be correlated with improved

cal performance. In other medical domains where

unication is crucial for safety, the relationship

en communication skills and error has been examined

losely, with highly detailed teamwork assessment

eing developed.

ary

l care teams perform many activities where effective

unication is crucial for ensuring patient safety and

ng susceptibility to error. To develop valid team

g and assessment tools for improving teamwork in the

ive care unit there is a requirement to better

tand and identify the specific communication skills

ant for safety during the provision of intensive care

ine.

ords

unication, error, intensive care unit, patient safety,

ork

rit Care 13:732736.olters Kluwer Health | Lippincott Williams & Wilkins.

Psychology, University of Aberdeen, Kings College, Aberdeen andrvices Research Unit and Intensive Care Unit, University of Aberdeenen Royal Infirmary, Aberdeen, Scotland, UK

ence to Mr Tom Reader, School of Psychology, University of Aberdeen,ge, Aberdeen, Scotland, UK, AB24 2UB

224 273212; fax: +44 1224 273211; e-mail: tom.reader@abdn.ac.uk

pinion in Critical Care 2007, 13:732736

ion

nsive care unit

olters Kluwer Health | Lippincott Williams & Wilkins

ventasubstas a handsafetand mrendmediandcompbersmajo[2,3].condcommbeen[6]. Rbetwundeinducatioare tundeThusmunpatiereseathe Iacute

ComintePatiesuscenatioted tharmdurin[9].incidpatiemediwereing thincidntly shounication in critical care teams has been

wn as a contributing factor to adverse events.

Resequense of review Intro uctionh in healthcare has shown that patients fre-experience unnecessary harm as a result of pre-e medical errors. These events can result in thetial and unnecessary suffering of patients, as wellfinancial cost in terms of extended hospital stays

gation costs [1]. In terms of managing patientithin the intensive care unit (ICU), the complexltidisciplinary nature of intensive care medicineit particularly susceptible to the occurrence oferrors. Within high-risk settings such as aviationlear power, which share similar issues of workity, poor communication between team mem-frequently been identified as a causal factor incidents that have resulted in large loss of lifeithin these settings, substantial research has beened to understand the factors that influence teamnications [4,5], and team-training courses haveveloped to train and assess communication skillsearch in the ICU has shown poor communicationteam members to be a common causal factor

ing adverse events [7], yet unlike other high-riskes, the relationship between team communi-and safety in ICUs is less well understood, asfactors that influence team member interactionsoth normal and stressful operating conditions.here is a requirement to clarify how the com-ion behaviours of clinicians can contribute tosafety in the ICU [8]. This article considers recentinto aspects of communication and error within, and briefly considers work in similarly complexedical settings.

unication skills and error in theive care unitin the ICU have been shown to be particularly

ible to experiencing a medical error. The multi-Sentinel Events Evaluation study has documen-number of critical incidents (an occurrence that, or could have harmed, a patient) that occurstandard 24-h period in ICUs across 29 countriesa sample of nearly 2000 adult patients, critical

ts were found to affect approximately 20% of. The most frequent errors were associated withions, and lines, catheters and drains, and patientsost susceptible to error at midmorning. Consider-elatively high likelihood of experiencing a critical

particular, the relationship between safety and communi-cation error in the ICU has been recognized for some time[7]. In ogationsfound toccurredunit, therrors. Ahave alscare reccollaborshown treduced

Error-recommurecentlyincidentributorto nonteing), wias cont[13]. Tcontribuwith littmost suproblemcolleagusafety-rdata forcriticaland anofrom 23that themedicatdeliverylines, tinvolvincause pfactorsteam faof thosewrittenrelatedduring hleadershor writtincidenchangesbeing pmationtransferfactors[14] hteam-tra(e.g. mu

plinary communication during patient decision-making.Furthermore, ensuring that junior team members feel

to cr ty.

ndediffetietividismntvent rarece

disAtg dcotedivemaorsd. Lmpps heenof-lerlemof-lde

iesueru

y.n apatthtearmarcdetea

mim-fidutiv

Communication and error in the ICU Reader et al. 733ne of the most extensive human factors investi-of error in the ICU, Donchin and colleagues [10]hat although nurse and doctor communicationsin just 2% of all activities performed in their

ese were associated with over a third of detectedlongside safety, communication skills in the ICUo been shown to be important for the quality ofeived by patients. For example, high levels ofation between nurses and doctors have beeno result in improved patient mortality rates andaverage patient length of stay [11,12].

porting systems now frequently focus upon poornication as an antecedent to error in the ICU. Aconducted analysis of published ICU critical

t studies found that just under half of all con-y factors underlying critical incidents were relatedchnical skills (e.g. teamwork and decision-mak-th poor communication frequently being reportedributing to the occurrence of critical incidentshe review concluded that information on thetory role of communication is often superficial,le analysis being performed on the teammemberssceptible to error, or the specific communications that result in critical incidents. Pronovost andes [14] recent report on web-based patienteporting systems has provided a rich source ofunderstanding the role of poor communication inincidents. Their reporting system was voluntarynymous, and collected data on 2075 incidentsICUs over a period of 24 months. It was foundmost common forms of error were related to

ions (42% of incidents), incorrect or incompleteof care (20%), equipment failure (15%), and

ubes, and drains (13%). Of those, the eventsg lines, tubes, and drains were most likely toatient harm (48% of events). A wide range ofwere found to underlie critical incidents, withctors contributing to 32% of errors. In total, 57%errors were related to problems with verbal orcommunication during routine care, 37% wereto problems with verbal or written communicationandovers, 21%were related to team structure andip, and 6% were related to problems in verbalen communication during crises. Examples ofts included clinicians not communicating orderto nursing staff, incorrect patient informationassed between different teams, and poor infor-dissemination on severely ill patients beingred to the ICU. Due to the prevalence of teamin critical incidents, Pronovost and colleaguesave stressed the importance of implementingining programmes and team-based activitiesltidisciplinary rounds) that encourage interdisci-

ableseniosafet

Beyoof mthe eon painitiamultteampatieintereven[15]wereintercare.estinandreporpositinforof errlishethe ifor imnursebetwend-and pprobend-provi

StudcommFurthcommsafetcatiohowfromhowperfoReseproviICU

Comin sHighcommeffecommunicate openly on issues of patient care witheam members is also identified as crucial for

studying the role of communication in incidencescal error in the ICU, research has also examinedct of improving interdisciplinary communicationnt safety [15]. In the US, quality improvementes have involved implementing physician-ledciplinary rounds where clinicians encourage allembers to communicate and contribute to thedecision-making process. The introduction of thistion was associated with a decline in adversetes over the course of a year. Jain and colleaguesported that better communications during roundsntral to the improvements, as they enhancedciplinary teaching and the coordination of patienttitudinal research has also provided some inter-ata, finding that positive perceptions of teamworkmmunication are associated with lower self-error rates in the Netherlands [16]. Specifically,perception of factors such as timely and accuratetion transfer was associated with lower perception, although no predictive relationships were estab-astly, Puntillo andMcAdam [17] have discussedortance of clear and constructive communicationroving end-of-life care in the ICU. Specifically,ave reported that there is poor communicationnurses and doctors during decision-making on

ife care [17]. In particular, differences in trainingspective are cited as resulting in communications, with a lack of communication on issues ofife care resulting in poorer information beingd to patients families [18].

of errors in the ICU have frequently shown poornication to be a causal factor in critical incidents.more, some insight has been provided on thenication skills important for maintaining patientWhile examining the link between communi-nd clinician error is important for understandingient harm occurs in the ICU, the data returnedese studies are limited in terms of understandingm communication behaviours can affect teamance during routine and emergency situations.h using critical care simulators, however, hasd some insight into communication skills andm performance.

unication skills and team performanceulator studieselity simulators can be used to investigate thenication skills that are most likely to result ine team performance, and research has been done

on the communication behaviours of intensive care teamsduring simulated emergencies. For example, Lighthalland colthe ICUstandinganalysisance fotheir caloadedbeing presultedin someon the i

High-fidexamineduringThrougresusciton theirleadershresourcecare usbehavioresidentclearlystaff feand nonpoorly iacknowdirectedparticipwho haproduceReliabilsistencyindicatiused tobetweenteam pe

Ottestadscoringteamwowere asa high-betweenexamineresidenttherapismanagedimensileadershunderpisions. Fclear a

communications, delegated tasks effectively, communi-cated the urgency of patient problems, prioritized aspects

reortny iatelemorrrmddiviou

micstigpelatenrchuanndre,me

amanare.cors we ipogrotte, akilberuplense orvalulexmarmifiesamrogotmfro

734 Ethical, legal and organizational issues in the intensive care unitleagues [19] study of critical event scenarios indemonstrated the utility of simulation for under-communication and errors in ICU teams. Theirof communication errors during team perform-und that team members did not communicatere priorities to one another; that physicians over-nurses with requests, leading to key tasks noterformed promptly; that ineffective leadershipin ineffective use of time and personnel; and thatinstances there was an absence of communicationnitiation of new therapies.

elity simulator studies have also been used tothe communication abilities of ICU residents

the resuscitation of critically ill patients [20].h analysing videos of Canadian ICU residentsating simulated patients, residents were assessedcommunication skills alongside their skills forip, problem solving, situational awareness andutilization. Experts on resuscitation and critical

ed a behavioural rating system to assess theurs of residents. The communication skills ofs were rated most highly if they communicatedat all times, encouraged input and listened toedback, and consistently used directed verbal-verbal communications. Residents were ratedf they did not communicate with staff, did notledge staff communications, and never usedverbal and non-verbal communications. Overall,ants were found to perform well, with residentsd 3 years postgraduate training being found tohigher scores than those with 1 years training.ity testing, however, found relatively poor con-in the rating of communication performance,

ng that some revision was required of the systemrate performance. Furthermore, no relationshipcommunication skills and objective measures ofrformance was reported.

and colleagues [21] have also developed asystem for assessing the communication andrk skills of critical care teams. In particular, teamssessed during the management of septic shock infidelity patient simulator, with the relationship

teamwork and technical performance beingd. For this study, participants included ICUs and a support team of nursing staff, respiratoryts and anaesthesiologists. Based on crew resourcement (CRM) principles from aviation, sevenons of behaviours (e.g. teamwork, planning,ip) were assessed with good communicationnning high levels of performance on most dimen-or example, teams were rated highly if they madend direct requests, employed closed loop

of cacomfmatiopoorldelegproband cperfoan abehacomm

CommedInvehavethe rin inreseacommcine,the fitheatcare

WillisivetheatpoorfactoThesof resbacknot aturesand snumcommexamand eawarObseusefucommcompinforperfoidentwhenthe tefor pto anmove(e.g.effectively, made sure all team members wereable with their allotted tasks, and shared infor-on the patient care plan. Teams were ratedf they did not request appropriate information,tasks, or communicate priorities and patient

s. Teams rather than individuals were assessed,elations were found between ratings on technicalance (e.g. diagnosis, antibiotic use, placingtional intravenous catheter) and scores on theural aspects of performance (i.e. teamwork andnication).

unication research in other acuteal environmentsations of communication and error in the ICUrovided useful information for understandingtionship between teamwork and patient safetysive care medicine. An extensive amount of, however, has examined the relationship betweennication and error in other domains of acute medi-d especially within the operating theatre. Whileings from these studies relate to the operatingthey feature themes that are pertinent to intensivedicine.

s et al. [22] have recently conducted an exten-lysis of communication errors in the operatingIn an examination of 328 incident reports wheremmunication contributed to errors, numerousere found to result in communication problems.

ncluded factors such as the ineffective delegationnsibilities, poor role clarity, shift changes, patientund information not being communicated, nursesnding patient rounds, hierarchical team struc-nd inaccurate assumptions on the knowledgels of team members. Based on these findings, aof detailed suggestions were made to improve

nication between surgeons and residents; for, improving documentation during handovers,uring that experienced surgeons are always madef the knowledge and skill base of junior residents.tional studies of surgical cases have also providedinformation on the relationship between poornication and error [23]. Observations on 10surgical cases found poor communication and

tion flow to have a negative effect on teamance as a whole. In total, 88 distinct events wered when information was lost or degraded (e.g.urgeons communicated patient information to), with 86% of these events having consequencesression of patients from one stage of the operationher. Furthermore, patient handovers and theent of patients from one phase of care to the nextm the operating theatre to the recovery room)

were most vulnerable for information loss, andinadequate discussion of clinical information was ident-ified asreview ocommonharmfulbetweenwas shofer betwhandovemunicatin the ocertaindiscussimembeof errorintensiv

Improvi

Developcation achallengto undeteamwoassessmsive tasimportaproficietions ancation wto be dICU capatientsplans, plife deciunits [3used tosignificaorder tofurthermunicatsafety. Acognitivvationsof cognof error

ConcluPoor coute to omore, iICU haand simcommuwith imdomain

and teamwork skills important for safety are less welldefined. As critical care teams perform a multitude of

itieiremicatfic

reof pighlspeout

nalLite

ncen

casfety

eickan

weam t

nkieinen D

eineade

righerap

onaeffealth

lentm thed 2scales.

nchhum0.

ggsysicrit C

orteens94;

adeJ Ais of

onofetydys. Cnica

in Mectiamwes tes.

n Berat:45inal

ntillrgetporperdur

oulait pa3:1

Communication and error in the ICU Reader et al. 735a commonly occurring error. Lastly, a recentf surgical malpractice claims identified the mosttypes of communication breakdown reported asto patients. Insufficient verbal communicationattending surgeons and other team members

wn to result frequently in poor information trans-een team members, with patient transfers andrs again being particularly susceptible to com-ion problems [24]. Thus communication studiesperating theatre have shown the importance ofcommunication skills (e.g. good handovers, teamons on clinical information, understanding teamr information needs) in reducing the probabilitys. These are likely to also be important for thee care environment.

ng communication in intensive care

ing tools for training and assessing communi-nd teamwork in the ICU presents a substantiale. Within surgery, attempts have also been maderstand andmodel the factors that predict effectiverk [25,26], and to develop team-training andent tools [27]. These tools are based on an exten-k analysis to understand the specific team skillsnt for safety and the behaviours that indicatency in those skills [28,29,30]. While interven-d tools do currently exist for improving communi-ithin the ICU [31], there remains significant workone. In particular, the work tasks performed byregivers are highly varied, with teams admitting, diagnosing illnesses, developing treatmenterforming complex procedures, making end-of-sions and liaising with families and other hospital2]. Furthermore, the communication strategiesmanage the activities have been found to varyntly depending on the task [33]. Therefore, indevelop tailored team-training interventions,

research is required to better identify the com-ion skills and behaviours crucial for maintainingrange of techniques exist to do this, including

e interviews, hierarchical task analysis, obser-during real and simulated performance, studiesition, attitudinal surveys and root-cause analysess.

sionmmunication and teamwork frequently contrib-ccurrence of medical error in the ICU. Further-nterventions to improve communication in theve resulted in reduced reports of adverse events,ulated scenarios have shown that effective

nication between team members is correlatedproved technical performance. Compared withs such as surgery, however, the communication

activrequmunspeci

RefePapersbeen h of ofAdditioWorld

1 Vi

2 Lusa

3 WJ M

4 Bote

5 KaWSa

6 WAc

7 Wth

8 LeofHe

9

VafroM

Largecountri

10 Doof30

11 BaphC

12 Shint19

13

ReBr

Analys

14

Prsa

This stu23 ICUcommu

15

Jainfte

Examinoutcom

16

vaop16

Attitud

17

Putaop

This panurses

18 Azun16s requiring effective communication, there is aent to better identify and understand the com-ion skills associated with safety in the ICU duringtasks.

nces and recommended readingarticular interest, published within the annual period of review, haveighted as:cial intereststanding interest

references related to this topic can also be found in the Currentrature section in this issue (p. 772).

t C. Patient safety. London: Elsevier; 2006.

D. The causes of human error. In: Redmill R, editor. Human factors incritical systems. Oxford: Butterworth Heinemann; 1997. pp. 3765.

K. The vulnerable system: an analysis of the Tenerife air disaster.age 1990; 16:571593.

rs C, Jentsch F, Salas E, et al. Analyzing communication sequences forraining needs assessment. Hum Factors 1998; 40:672679.

B, Palmer M. Communication and crew resource management. In:r M, Kanki B, Helmreich R, editors. Cockpit resource management.iego: Academic Press; 1993. pp. 99136.

r E, Kanki B, Helmreich R. Cockpit resource management. San Diego:mic Press; 1993.

t D, Mackenzie M, Buchan I, et al. Critical incidents in the intensivey unit. Lancet 1991; 14:676681.

rd M, Graham S, Bonacum D. The human factor: the critical importancective teamwork and communication in providing safe care. Qual Safcare 2004; 13:8590.

in A, Capuzzo M, Guidet B, et al. Patient safety in intensive care: resultse multinational Sentinel Events Evaluation (SEE) study. Intensive Care006; 32:15911598.e study documenting critical incidents from 220 ICUs across 29

in Y, Gopher D, Olin M, et al. A look into the nature and causesan errors in the intensive care unit. Crit Care Med 1995; 23:294

JG, Schmitt MH, Mushlin AI, et al. Association between nurseian collaboration and patient outcomes in three intensive care units.are Med 1999; 27:19911998.

ll SM, Zimmerman JE, Rousseau DM, et al. The performance ofive care units: does good management make a difference? Med Care32:508525.

r T, Flin R, Lauche K, et al. Nontechnical skills in the intensive care unit.naesth 2006; 96:551559.common causes found to underlie errors in ICU critical incident studies.

vost P, Thompson D, Holzmueller C, et al. Toward learning from patientreporting systems. J Crit Care 2006; 21:305315.analyses data from a web-based critical incident reporting study used inonsiderable information is presented on the relationship between teamtions and error.

, Miller L, Belt D, et al. Decline in ICU adverse events, nosocomialons and cost through a quality improvement initiative focusing onork and culture change. Qual Saf Healthcare 2006; 15:235239.he effect of a quality improvement initiative on teamwork and patient

euzekom M, Akerboom SP, Boer F. Assessing system failures ining rooms and intensive care units. Qual Saf Healthcare 2007;50.study examining perceptions on teamwork and error.

o K, McAdam A. Communication between physicians and nurses as afor improving end-of-life care in the intensive care unit: challenges andtunities for moving forward. Crit Care Med 2006; 34:S332S340.is a review of the literature on communication between physicians anding end-of-life care.

y E, Pochard F, Chevret S, et al. Meeting the needs of intensive caretient families: a multicenter study. Am J Respir Crit Care Med 2001;35139.

19 Lighthall GK, Barr J, Howard SK, et al. Use of a fully simulated intensive careunit environment for critical event management training for internal medicineresidents. Crit Care Med 2003; 31:24372443.

20

Kim J, Neilipovitz D, Cardinal P, et al. A pilot study using high-fidelity simulationto formally evaluate performance in the resuscitation of critically ill patients: theUniversity of Ottawa Critical Care Medicine, High-Fidelity Simulation, andCrisis Resource Management I Study. Crit Care Med 2006; 34:21672174.

This article presents a simulator-based investigation of teamwork during patientresuscitations.

21

Ottestad E, Boulet J, Lighthall G. Evaluating the management of septic shockusing patient simulation. Crit Care Med 2007; 35:769775.

This paper reports a simulator-based investigation of the relationship betweennontechnical and technical skills during the management of septic shock.

22

Williams R, Silverman R, Schwind C, et al. Surgeon information transfer andcommunication: factors affecting quality and efficiency of inpatient care. AnnSurg 2007; 245:159171.

This is an investigation of errors in surgery where communication has beenidentified as a key causal factor. It highlights aspects of communication in surgerythat are also relevant to the ICU.

23

Christensen C, Gustafson S, Roth EM, et al. A prospective study of patientsafety in the operating room. Surgery 2006; 139:159173.

This is an observational study of communication and information flow duringsurgery. It highlights aspects of communication in surgery that are also relevantto the ICU.

24

Greenberg C, Regenbogen S, Studdert D, et al. Patterns of communicationbreakdown resulting in injury to surgical patients. J Am Coll Surg 2007;204:533540.

This article reviews surgical malpractice cases where communication breakdownsresulted in error.

25

Healey A, Undre S, Vincent C. Defining the technical skills of teamwork insurgery. Qual Saf Healthcare 2006; 15:231234.

This article presents a discussion of the role of teamwork skills in surgery.

26

Undre S, Sevdalis N, Healey A, et al. Teamwork in the operating theatre:cohesion or confusion? J Eval Clin Pract 2006; 12:182189.

This article reports an investigation of perceptions of teamwork and team rolesamong operating theatre staff.

27 Unsworth K, West M. Teams: The challenges of cooperative work. In: ChanelN, editor. Introduction to work and organizational psychology. Cornwall:Blackwell; 2000. pp. 327346.

28

Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system forsurgeons nontechnical skills. Med Educ 2006; 40:10981104.

This article reports on the development of a behavioural ratings system forsurgeons teamwork skills.

29 Flin R, Maran N. Identifying and training nontechnical skills for teams in acutemedicine. Qual Saf Healthcare 2004; 13:8084.

30 Mishra A, Catchpole K, Dale T, et al. The influence of nontechnical perfor-mance on technical outcome in laparascopic cholecystectomy. Surg Endosc(in press).

31 Pronovost PJ, Berenholtz SM, Dorman T, et al. Improving communications inthe ICU using daily goals. J Crit Care 2003; 18:7175.

32

Malhotra S, Jordan D, Shortliffe E, et al. Workflow modelling in critical care:piecing together your own puzzle. J Biomed Inform 2007; 40:8192.

This article presents a task analysis of different work activities performed by ICUcaregivers.

33 Albolino S, Cook R, OConnor M. Sensemaking, safety, and cooperative workin the intensive care unit. Cog Tech Work (in press).

736 Ethical, legal and organizational issues in the intensive care unit

Communication skills and error in the intensive careunitIntroductionCommunication skills and error in the intensive care unitCommunication skills and team performance in simulator studiesCommunication research in other acute medical environmentsImproving communication in intensive care

ConclusionReferences and recommended reading