Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals
Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals
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DOI：
10.1136/bmjqs.2010.040238
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发表时间：
2011-03-01
影响因子：
5.4
通讯作者：
Mogensen, Torben
中科院分区：
文献类型：
--
作者：
Rabol, Louise Isager;Andersen, Mette Lehmann;Mogensen, Torben
导言：医护人员之间缺乏团队合作和沟通与患者安全事件有关。然而，导致这些问题的组织因素尚未得到探索。根本原因分析(RCA)使用人的因素思维来分析严重患者安全事件背后的系统。本研究的目的是从组织的角度回顾RCA报告(RCAR)，以了解医院员工之间言语沟通错误的特征。方法：两名独立评分员分析了2004-2006年间在丹麦6家医院进行的84份RCAR，以了解移交错误和团队合作中的错误等言语沟通错误的描述和特征。结果：在44份报告(52%)中，评级人员找到了对言语沟通错误的描述。这些错误包括移交错误(35(86%))、不同工作人员组之间的沟通错误(19(43%))、误解(13(30%))、初级和高级工作人员之间的沟通错误(11(25%))、在发言时犹豫(10(23%))和团队合作中的沟通错误(8(18%))。卡伯值为0.44~0.78。通过电话进行非程序化的沟通和信息交换，涉及到单位之间的转移和其他专科的会诊，是特别脆弱的过程。结论：考虑到存在偏见的风险，超过一半的RCAR将工作人员之间的错误语言沟通描述为严重患者安全事件的根本原因或促成因素。RCARS对这些事件的丰富描述揭示了与这些错误相关的组织因素和需求。
Introduction: Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective.Method: Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork.Results: Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes.Conclusion: With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.