RESEARCH ASSIGNMENT GROUP 2
1. INTRODUCTION AND SCOPE
The literature consistently identifies communication among healthcare professionals (HCPs) —
including physicians, nurses, pharmacists, and allied health staff — as a primary determinant of
patient safety. Modern healthcare is a multidisciplinary effort; therefore, the "handoff" of
information between these disciplines is where care most frequently fractures. The consensus in the
literature is that effective interprofessional communication is not merely a soft skill but a critical
clinical competency directly linked to mortality and morbidity rates.
2. KEY THEMES IN THE LITERATURE ARE:
A. Communication Failures as a Root Cause of Error:
The most prominent theme in the literature is the correlation between communication breakdowns
and adverse sentinel events (unexpected occurrences involving death or serious injury).
1. The Data: Research by The Joint Commission has historically cited communication failures as
the leading root cause of sentinel events, often exceeding clinical incompetence.
2. Malpractice and Mortality: A landmark report by CRICO Strategies (benchmarking data from
Harvard medical institutions) analyzed 23,000 medical malpractice lawsuits. They found that
communication failures were a factor in 30% of cases, resulting in 1,744 preventable deaths and
over $1.7 billion in malpractice costs over a five-year period.
3. Hierarchy: Studies often point to "steep hierarchies" (e.g., nurses hesitating to correct surgeons)
as a barrier to safety. When communication is flattened and inclusive, patient outcomes improve
because errors are caught earlier.
B. The "Handover" Vulnerability
Literature identifies the "handover" or "handoff"—shift changes, transferring patients from ER to
ICU, or discharge planning—as the single highest-risk moment for patient health.
1. Information Asymmetry: When information is siloed (e.g., a nurse knows the patient is allergic
to a drug, but the new physician does not), patients suffer medication errors and delays in treatment.
2. Continuity of Care: Literature suggests that standardized handover protocols significantly
reduce "preventable adverse events" (PAEs) by ensuring continuity of the "care narrative."
C. Impact on Length of Stay (LOS) and Readmissions
Effective communication does not just save lives; it improves efficiency.
1. Team Collaboration: Studies on "Interprofessional Collaborative Practice" (IPCP) show that
when teams communicate effectively during rounds, hospital Length of Stay (LOS) decreases.
2. Discharge Planning: Poor communication among workers during discharge (e.g., between the
hospitalist and the primary care physician) is a primary predictor of 30-day readmission rates.
D. Standardization: The SBAR Model
A significant portion of recent literature focuses on how to fix these issues. The most cited
intervention is SBAR (Situation, Background, Assessment, Recommendation).
1. Evidence: Implementation of SBAR has been shown to reduce unexpected patient deaths and
improve nurse-physician relationships by creating a "shared mental model." It removes ambiguity
from clinical conversations.
4. REFERENCES
If you are writing a paper, these are high-impact sources you should cite:
1. The Joint Commission. (Various Annual Reports). Sentinel Event Data: Root Causes by Event
Type. (Establishes communication as a primary cause of medical error).
2. CRICO Strategies. (2015). Malpractice Risks in Communication Failures. (Provides the statistic
regarding 1,744 deaths linked to communication).
3. Sutcliffe, K. M., Lewton, E., & Rosenthal, M. M. (2004). Communication failures: an insidious
contributor to medical mishaps. Academic Medicine, 79(2), 186-194. (A foundational paper on how
systemic communication failures lead to errors).
4. Dingley, C., Daugherty, K., Derieg, M. K., & Persing, R. (2008). Improving Patient Safety
Through Provider Communication Strategy Enhancements. In: Henriksen K, et al., editors.
Advances in Patient Safety: New Directions and Alternative Approaches. (Discusses SBAR and
standardized tools).
5. Manser, T. (2009). Teamwork and patient safety in dynamic domains of healthcare: a review of
the literature. Acta Anaesthesiologica Scandinavica, 53(2), 143-151. (Reviews how teamwork
quality directly impacts clinical safety).
6. Institute of Medicine (IOM). (1999). To Err Is Human: Building a Safer Health System.
Washington, DC: National Academy Press. (The seminal report that launched the modern patient
safety movement, heavily emphasizing system/communication failures over individual blame).
7. Employed the Gemini 2.5 Flash generative AI model (Google, 2025) by prompting it to
identify key historical themes in the literature. The resulting themes were then independently
researched and verified using traditional scholarly databases."
GROUP MEMBERS
KOTOKU MAKAFUI ROWAN-DEAN
NMCKTRGN240098
ANYOMI LAURA SEFAKOR
NMCKTRGN240091
ESHUN JENNIFER
NMCKTRGN240036
GEBE BELINDA KAFUI
NMCKTRGN240172
DZOKOTO PATRICIA YAWO
NMCKTRGN240115
NKANSAH NAADAH DANKWAH
NMCKTRGN240069
KETORMANYAH NAMISIAH
NMCKTRGN240047
AHORLU JOSEPH EDUDZI
NMCKTRGN240084
ADEVU EVANS DANIEL KWAME
NMCKTRGN240030