Problematic Health Care Communication
The Joint Commission continues to identify errors in communication as a root cause of sentinel events.10 In addition, The Joint Commission has identified improving health care communication as one of the 2015 National Patient Safety Goals.11 The work of nurses is complex, and errors in health care communication occur when health care team members are under stress, in high-task situations (eg, critical junctures during patient transfer), and when interrupted during an episode of communication, all of which compromise the accuracy and completeness of information transfer. Nurses are well educated to manage an array of tasks related to decision making, prioritizing, and organizing, but interruptions can interfere with this cognitive process.12 In addition, team members are more prone to errors when they do not have a clear understanding of their role; do not feel supported (eg, administratively, interpersonally, professionally), respected, valued, understood, or listened to; and lack adequate training in providing high-quality health care information to one another and to the patient.13