Description
Determination of which contributing factor(s) related to communication are known.
On-Screen Instructions
Check all that apply.
Field Type
Checkbox (multiselect)
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Healthcare Team Member Factors
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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
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Communication related to handoffs, handovers or shift reports (select
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reports”)
Communication between units at different facilities in the same healthcare system (select
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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
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reports”)
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Communication between unit staff and supervisor or manager (select
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staff”)
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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
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reports”)
Communication between unit staff and supervisor or manager (select
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staff”)
Communication among healthcare professionals working within a designated team or service (select
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teams”)
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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
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reports”)
Communication among healthcare professionals working within a designated team or service (select
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teams”)
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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
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Excludes
Communication between unit staff and supervisor or manager (select
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staff”)
Communication among healthcare professionals working within a designated team or service (select
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teams”)
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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
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Ineffective communication within a unit in a facility contributed to the event.
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Excludes
Across staff on multiple units (select
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“Across units”)
Communication related to handoffs, handovers or shift reports (select
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reports”)
Communication between unit staff and supervisor or manager (select
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staff”)
Communication among healthcare professionals working within a designated team or service (select
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teams”)
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Ineffective communication with other organizations or outside providers contributed to the event.
Includes
Different facility or location within the same healthcare system
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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
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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
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“Language”)
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| title | Definition |
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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
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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
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plan”)
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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
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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
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Patient is difficult to understand (select
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Patient has language barrier (select
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“Language”)
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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)
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| title | Definition |
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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.
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Includes
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Additional Guidance
Communication factors may be related to any spoken or written communication between anyone in a facility, including, but not limited to, providers, staff, patients, and patient families. Ineffective communication is communication that was inaccurate, incomplete, ambiguous, misunderstood by the recipient, or not timely.
History
Start Date | 2006 |
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End Date | n/a |
Change History | Spring 2012: PSRP Implementation March 2013: added “Understanding discharge instructions or plan” for ASCs May 2013: added “Understanding discharge instructions or plan” for hospitals January 2016: added “Patient did not use call light” and “Patient unable to communicate” |