Monday, September 1, 2014

Miscommunication kills

Introduction: To Err Is Human: Building a Safer Health System (2000) revealed risks associated with adverse events in hospitals in the USA. Such adverse events are not new. In 1976 Illich named such adverse events as iatrogenesis. In this article, we define iatrogenesis in terms of the preventable harm that people experience in association with health practitioners. In a New Zealand study, Davis, Lay-Yee, Bryant, Scott, Johnson, and Bingley, (2002) reported an iatrogeneic rate 12.9% for those hospitalised. This involved a retrospective study of documented incidences across 13 NZ hospitals. The undocumented adverse event rate can be presumed to be much higher.
Evans (2007) reified the staggering size of these preventable events by providing the following provocative illustration: These 1500 deaths are equivalent to four Boeing 747’s crashing in New Zealand every year, a rate that is three times the road traffic death rate, and double the deaths from both homicide and suicide (Evans 2007, p. 16).[Computer generated photo of the collision. Photo/] This study set out to investigate the concerns raised with regard to communications being implicated in the preventable harm caused by health practitioners in New Zealand in current times. The safe provision of health and disability services in New Zealand is overseen by the Office of the Health and Disability Commissioner(HDC).
Method: In this study we explored miscommunication as an ongoing contributor to iatrogenesis in healthcare practice in New Zealand. This involved an analysis of complaints made to the HDC. The most recent 100 decisions and case notes lodged with the HDC between February 2012 and May 2014 were analysed. These cases can be accessed at The analysis investigated the incidence of preventable harm, the nature of such harm (as much as it can be known from the case notes), and the nature of the miscommunications involved.
An initial reading of the first ten cases provided words that were then used in the setting up of codes that could be identified with NVivo software. An initial 'first pass' of the data was then made identifying words commonly associated with communications, such as communicat*, talk*, document* writ* email, text* This technology aided analysis was then extended further by making use of the coding already employed by the HDC in terms of patient rights and coding could then be made wherever a breach of a particular right occurred. Specifically, Right 5 as a category always involves a breach of communications. Right 5 being the right to effective communication. Similarly breaches upheld by the HDC involving breaches to Right 6 The right to be fully informed and Right 7 The right to make an informed choice and informed decision are also only breached where communications have been at fault. Following a first pass of the NVivo software on the pdf files of the case notes, the remaining case studies were manually reviewed and the coding expanded with terms that had previously not been loaded as being relevant to communications. A further review of cases that fell outside of the NVivo analysis was undertaken by both authors resulting in the further classification of studies where the software did not recognise a breach in communications but where the authors did. The absence of communication, named in the literature as 'silence kills', being particularly evident with what is not spoken of or documented being equally relevant in the provision of appropriate health care.
Findings: Miscommunications was found to be implicated in 99 out of the 100 HDC case notes reviewed. (Refer to pie graph depicted on the conference poster.) In the one case where communications was not mentioned, it is nonetheless possible that had information between a client, their General Practioner and a pathologist been communicated then a different approach to the reading of a biopsy may have occurred. A further analysis was undertaken identifying the forms of miscommunications evident and the outcomes for clients particularly in regard to preventable suffering, disability, and death. (A breakdown of this data is depicted on the conference poster.) Of particular note that expands on earlier research into communications related iatrogenesis is the multi-model nature of health related communications in current times. One third of the cases analysed involved technologically mediated communications, these included telephone calls, text messaging, faxed communications, and computer mediated communications such as emails. While the technology is recognised as having influence, miscommunications did not occur in any of the reported discussions and case notes without there also being a human element. While media representation tends to conflate what is new with also being causative, this is an attribution error. Our findings provide irrefutable evidence of the need for healthcare practitioners to have well-developed interpersonal communication skills. The analysis also identified the need for health practitioners working with emergent technologies to understand how these technologies enhance or hinder practice.
Conclusions: As has been previously reported in the literature, the incidence of miscommunication within the health sector remains a serious and critical concern, one implicated in preventable deaths, as well as in the development of significant and ongoing disability, delays to treatment and the development of needless distress. What is reported on here is an uncomfortable truth. Such findings are not reported on lightly. In the research of sensitive subjects there is also demonstrated risk with areas deemed sensitive remaining unreported. Consideration is given here for looking forward rather than back, for 'what is' need not define 'what can be'; or as phrased by Law(2012), "reality is not destiny". We have the scope to alter how communications are taught and learned. Shifting the acquisition of communication skills from mastery of content to instead sharing a common skill set and practicing these inside of processes where we as health professionals learn to talk with each other,is but one step forward on this much needed path.
References Bahn, S., & Weatherill, P. (2012). Qualitative social research: a risky business when it comes to collecting ‘sensitive’ data. Qualitative Research, 1-17. doi:10.1177/1468794112439016 Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A. J., & Schug, S. (2002). Adverse events in New Zealand public hospitals I: Occurrence and impact. The New Zealand Medical Journal, 115(1167). Dickson-Swift, V., James, E. L., & Liamputtong, P. (2008). Undertaking sensitive research in the health and social sciences: Managing boundaries, emotions and risks. Cambridge, MA: Cambridge University Press. Evans, S. (2007). Silence kills--challenging unsafe practice. Kai Tiaki: Nursing New Zealand, 13(3), 16-19. Health and Disability Commissioner Act 1994. Health and Disability Commissioner. (2004). Code of Health and Disability Services Consumers’ Rights. Retrieved September 1, 2014, from Illich, I. (1976). Limits to medicine; Medical nemesis: The expropriation of health. London, England: Marion Boyars. Law, J. (2012). Collateral realities. In F. D. Rubio & P. Baert (Eds.), The Politics of Knowledge (pp. 156-178). Retrieved from

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