Patient injury may follow a breakdown in communication between health care providers. Greenberg et al identified various patterns seen in the care of surgical patients. The authors are from Brigham and Women's Hospital, Harvard University and Massachusetts General Hospital in Boston.
Failures:
(1) failure to notify the attending physician of a problem or serious event
(2) failure to comprehend significance of a finding
(3) failure to clearly establish responsibility
(4) failure to follow protocol
Contributing factors:
(1) status asymmetry (one person has greater authority or prestige than the other)
(2) transfer in care (hand-off, handing over)
(3) change in patient location
(4) ambiguity in roles
(5) high workload or competing tasks
(6) assuming that a message (left with secretary, sent by fax, sent by email) got through
where:
• Problems associated with handing-off is more likely to be a problem over weekends, holidays or vacations, when a key person may be inaccessible.
• A physician on call may lack key information relevant to a particular patient.
• One aspect not touched upon was antagonism or other negative feelings between the providers.
