Child Health PSO has identified a safety concern related to communication failures in the diagnostic process. This alert was developed after conducting a common cause analysis of the Child Health PSO database. In collaboration with industry experts, including Children's Hospital Association Chief Medical Officer, Chief Medical Information Officer, Chief Nursing Officer Forums and PSO member experts, pivotal points of communication were identified that organizations should consider exploring to mitigate communication failures that lead to diagnostic errors.
Child Health PSO found over half of member children's hospitals reported failures in communication (e.g., handoffs/handovers, diagnostic timeouts, escalation plans). Of those cases, the most serious harm, ranging from moderate permanent harm to death, occurred 57% percent of the time. The harm noted in these cases is disproportionally higher to the harm distribution for all PSO submitted cases.
An organization's performance is resilient if it can function as required under expected and unexpected conditions1. Communication failures are complex for a variety of reasons. Contributing to the complexity is the inability to overcome misinterpretations and incorrect assumptions of information.
- Diagnostic Tests
- Results are misinterpreted and/or not followed-up in a timely manner (e.g., lack of follow-up call after emergency department visit).
- Differential Diagnoses
- Alternative diagnoses are not identified and managed within the care team.
- Escalation Plans
- Plans for escalation are not established prior to patient status changes. Such plans should include when to escalate, how to escalate and to whom to escalate.
- Questioning Attitude-Culture
- Members of the care team don't feel empowered to question the decision/authority of another team member.
- Stating "I Don't Know"
- Members of the care team lack mechanisms or the confidence to communicate uncertainty with patients, families and other team members (e.g., providing an answer when unsure of situation vs. deferring to expertise or following up later).
Access Child Health PSO's actionable learning toolkit, Improving Communication to Enhance Diagnostic Safety.
- Recognize key communication vulnerabilities in the following case studies:
- The Voice of the Patient
- Conveying an Escalation Plan
- It's Okay to Say "I Don't Know"
- Questioning Attitude
- Communicating Diagnostic Results
- Assess your internal communication gaps in the diagnostic process using the Gap Analysis tool.
- Conduct a pause in patient care to re-evaluate the patient's diagnosis and medical response to treatment using the Team Diagnostic Timeout template.The template can be customized for your organizational needs.
- Review additional resources available from the industry to amplify organizational knowledge.
- Allied health care teams (e.g., respiratory)
- Ambulatory care
- Clinical educators
- Clinical staff and leaders
- Emergency/urgent care
- Legal/risk management
- Medical leaders
- Nursing leaders
- Organizational leaders
- Patient safety
- Primary care
- Quality improvement
- Specialty care services
- Surgical leaders
What can I do with this alert?
- Forward to the recommended target audiences for evaluation.
- Include in your daily safety brief.
- Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm.
- Let us know what is working and what additional information you need.
1 Hollnagel, E. (2018). Safety-II in Practice Developing the Resilience Potentials. New York: Routledge.
PSO Patient Safety Team Experts:
- Allison Carballo, RN, MBA, Northwell Health (Cohen Children's Hospital)
- Anne Dykes, RN, M.S.N., ACNS-BC, Texas Children's Hospital
- Jeanann Pardue, M.D., East Tennessee Children's Hospital
- Tamara Johnson, B.S.N., CPHRM, Phoenix Children's Hospital
PSO Member Experts:
- Brian Wagers, M.D., Riley Hospital for Children at Indiana University Health
- Bridget Norton, M.D., MBA, Children's Hospital and Medical Center, Omaha
- David Chaulk, M.D., M.P.H., Primary Children's Hospital
- Gina Dawson, J.D., B.S.N., RN, CPHRM, Children's Hospital of The King's Daughters
- Grace Arteaga, M.D., Mayo Clinic Children's Center
- Holly Sealer, M.S.N., RN, PCNS-BS, Children's Hospital and Medical Center, Omaha
- Joe Grubenhoff, M.D., MSCS, Children's Hospital Colorado
- Kathryn Merkeley, M.H.S.A., B.S.N., RN, Children's National Medical Center
- Kristina Toncray, M.D., Seattle Children's
- Melisa Paradis, M.S.N., RN, CPN, CPPS, Children's Hospital and Medical Center, Omaha
- Merrilee Cox, M.D., Dayton Children's Hospital
- Nan Henderson, DNP, M.S.N.-Ed, RN, St. Jude Children's Research Hospital
- Tracy Chamblee, Ph.D., APRN, PCNS-BC Children's Health, Dallas
Advisors-Children's Hospital Association Forum Leads:
- Feliciano Yu, M.D., M.S.H.I., M.S.P.H., Arkansas Children's Hospital
- Laura Wood, DNP, M.S., RN, Boston Children's Hospital
- Marvin Harper, M.D., Boston Children's Hospital
- Matthew Denenberg, M.D., FACEP, FAAP, Helen DeVos Children's Hospital
- Paula Agosto, RN, M.H.A., Children's Hospital of Philadelphia
Subject Matter Expert:
- Andrew Olson, M.D., FACP, FAAP, University of Minnesota
Child Health PSO Staff:
- Emily Tooley, RN, M.S.N., CPPS, CPHQ
This alert is approved for general distribution to improve pediatric safety and reduce patient harm. This alert meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO.