Ineffective communication between representatives of different units or departments in a facility contributed to the event.

Includes

• One or more units within a facility

• Misinterpreted communication

• Incomplete, not timely, or inaccurate communication

Excludes

• Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams")

• Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

• Communication between units at different facilities in the same healthcare system (select “With other organizations or outside providers”)

Ineffective communication among any group of healthcare professionals from diverse fields who work to coordinate the care of a patient in a facility contributed to the event.

Includes

• Healthcare professionals in different disciplines working within a designated team or service (e.g., Rapid Response, Code Blue, Infection Prevention)

Excludes

• Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”);

• Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

Ineffective communication between provider and staff in a facility contributed to the event.

Includes

• Staff does not communicate with provider

• Provider does not communicate with staff

• Misinterpreted communication

• Incomplete, not timely, or inaccurate communication

Excludes

• Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

• Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

• Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Ineffective communication between supervisor and staff in a facility contributed to the event.

Includes

• Misinterpreted communication

• Incomplete, not timely, inaccurate communication

Excludes

• Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

• Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Ineffective communication related to handoffs, handovers or shift reports in a facility or between facilities contributed to the event.

Includes

• All healthcare professionals

• Misinterpreted communication

• Incomplete, not timely, or inaccurate communication

• Transfers of patients from one facility to another (also select “With other organizations or outside providers”)

Excludes

• Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

• Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Hard to read handwriting or a hard to read fax contributed to the event.

Includes

• Illegible printing or handwriting

• Printing too light to read clearly

• A healthcare professional’s temporary notes to self

Excludes

Ineffective communication within a unit in a facility contributed to the event.

Includes

Excludes

• Across staff on multiple units (select “Across units”)

• Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

• Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

• Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Ineffective communication with other organizations or outside providers contributed to the event.

Includes

• Different facility or location within the same healthcare system

Excludes

Any other factor related to communication among facility personnel, not included in the list above, which contributed to the event.

Includes

• Inadequate available information that is not covered by one of the existing factors

Excludes

Ineffective communication related to cultural differences between facility personnel and the patient or patient’s family contributed to the event.

Includes

• Failure to recognize cultural prohibitions and preferences

Excludes

• Language barriers (select “Language”)

A component of language that impacted the communication between patients and facility personnel contributed to the event.

Includes

• Spoken language

• American Sign Language (ASL)

• Pronunciation or accent

• Lack of or inappropriate translation services

Excludes

Miscommunication between facility personnel and the patient or patient’s family contributed to the event.

Includes

• Incorrect information regarding condition, medications, etc., provided to or by patient or patient’s family

Excludes

• Misunderstood or incorrect discharge instructions (select “Understanding discharge instructions or plan”)

Patient does not use call light to communicate needs with staff.

Includes

• Any reason a patient does not use a call light (e.g., patient cannot remember to use call light, patient desire for privacy or independence, patient does not want to bother staff)

Excludes

• Call light not available (select “Device , equipment, or supply availability”)

• Call light not working (select “Device, equipment, or supply Function (e.g., defective, non-working)”)

• Call light alarms turned off (select ““Device, equipment, or supply Use or selection by healthcare provider or staff” or “Device, equipment, or supply Use by patient”)

• Patient not provided instruction for using call light (select “Miscommunication”)

Patient’s physical inability to communicate contributed to the event.

Includes

• Nonverbal patient

• Patient unable to communicate due to clinical condition (e.g., ventilated, comatose)

Excludes

• Patient provides incorrect information or fails to disclose information to care team (select “Miscommunication”)

• Patient is difficult to understand (select “Miscommunication”)

• Patient has language barrier (select “Language”)

Ineffective communication impacting the patient’s understanding of discharge instructions or discharge plan contributed to the event.

Includes

• Missing, incomplete, or inaccurate information about: medications; next appointment; limitations; indications for provider evaluation of symptoms after discharge from facility

• Ineffective communication of discharge instructions (either written or verbal)

• Lack of confirmation of patient understanding)

Excludes

Any other factor related to communication between facility staff or providers and the patient or patient's family not included in the list above, which contributed to the event.

Includes

Excludes