2 Even more disturbing, communication failures are the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System, revealed that between 44,000 and 98,000 people die every year in U.S. According to the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National Center for Health Statistic’s list of the top 10 causes of death in the United States, they would rank number 5-ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast cancer, and gunshot wounds. Medical errors, especially those caused by a failure to communicate, are a pervasive problem in today’s health care organizations. These errors have the potential to cause severe injury or unexpected patient death. Lack of communication creates situations where medical errors can occur. When health care professionals are not communicating effectively, patient safety is at risk for several reasons: lack of critical information, misinterpretation of information, unclear orders over the telephone, and overlooked changes in status. Effective clinical practice thus involves many instances where critical information must be accurately communicated. During the course of a 4-day hospital stay, a patient may interact with 50 different employees, including physicians, nurses, technicians, and others.
In today’s health care system, delivery processes involve numerous interfaces and patient handoffs among multiple health care practitioners with varying levels of educational and occupational training.
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