Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

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Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. / Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris; Bjørn, Brian; Lilja, Beth; Mogensen, Torben.

I: Postgraduate Medical Journal, Bind 87, Nr. 1033, 01.11.2011, s. 783-9.

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningfagfællebedømt

Harvard

Rabøl, LI, Andersen, ML, Østergaard, D, Bjørn, B, Lilja, B & Mogensen, T 2011, 'Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals', Postgraduate Medical Journal, bind 87, nr. 1033, s. 783-9. https://doi.org/10.1136/pgmj.2010.040238rep

APA

Rabøl, L. I., Andersen, M. L., Østergaard, D., Bjørn, B., Lilja, B., & Mogensen, T. (2011). Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. Postgraduate Medical Journal, 87(1033), 783-9. https://doi.org/10.1136/pgmj.2010.040238rep

Vancouver

Rabøl LI, Andersen ML, Østergaard D, Bjørn B, Lilja B, Mogensen T. Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. Postgraduate Medical Journal. 2011 nov. 1;87(1033):783-9. https://doi.org/10.1136/pgmj.2010.040238rep

Author

Rabøl, Louise Isager ; Andersen, Mette Lehmann ; Østergaard, Doris ; Bjørn, Brian ; Lilja, Beth ; Mogensen, Torben. / Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. I: Postgraduate Medical Journal. 2011 ; Bind 87, Nr. 1033. s. 783-9.

Bibtex

@article{c7fbef7152c244468325687255751310,
title = "Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals",
abstract = "Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Method Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. Conclusion With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.",
author = "Rab{\o}l, {Louise Isager} and Andersen, {Mette Lehmann} and Doris {\O}stergaard and Brian Bj{\o}rn and Beth Lilja and Torben Mogensen",
year = "2011",
month = nov,
day = "1",
doi = "http://dx.doi.org/10.1136/pgmj.2010.040238rep",
language = "English",
volume = "87",
pages = "783--9",
journal = "Postgraduate Medical Journal",
issn = "0032-5473",
publisher = "B M J Group",
number = "1033",

}

RIS

TY - JOUR

T1 - Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

AU - Rabøl, Louise Isager

AU - Andersen, Mette Lehmann

AU - Østergaard, Doris

AU - Bjørn, Brian

AU - Lilja, Beth

AU - Mogensen, Torben

PY - 2011/11/1

Y1 - 2011/11/1

N2 - Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Method Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. Conclusion With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

AB - Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Method Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. Conclusion With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

U2 - http://dx.doi.org/10.1136/pgmj.2010.040238rep

DO - http://dx.doi.org/10.1136/pgmj.2010.040238rep

M3 - Journal article

VL - 87

SP - 783

EP - 789

JO - Postgraduate Medical Journal

JF - Postgraduate Medical Journal

SN - 0032-5473

IS - 1033

ER -

ID: 40206061