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When Miscommunication Becomes a Medical Risk

  • Writer: Tristan
    Tristan
  • Feb 24, 2025
  • 5 min read

Updated: Sep 11, 2025


Illustration of two people using tin-can telephones with tangled string between them, symbolizing miscommunication and confusion.
"When communication gets tangled, patient safety is at risk — clarity saves lives."

Healthcare runs on conversations—between clinicians, across shifts, and with patients and families. When those conversations break down, even briefly, the results can be serious. Miscommunication is one of the most fixable causes of patient harm, yet it happens every day because teams are busy, systems are fragmented, and information gets lost in the shuffle. World Health Organization



Why miscommunication happens


Even the best teams struggle in environments where:

  • Handoffs are rushed. Shift changes, cross-coverage, and referrals compress critical details into minutes. If the “must-know” items aren’t clearly passed along, care plans drift. The Joint Commission has repeatedly warned that inadequate handoffs contribute to sentinel events such as wrong-site procedures, treatment delays, and medication errors. Joint Commission digitalassetsjointcommission.org

  • Records are fragmented. Lab results in one system, imaging in another, notes in a third—clinicians spend time hunting for context instead of acting on it. AHRQ’s Patient Safety Network highlights handoffs as a persistent risk point during inpatient care. PSNet

  • Patients leave unsure of what to do. Health literacy, language differences, and stress make instructions hard to absorb. Without a quick check for understanding, even good advice goes unused. AHRQ’s “teach-back” method exists for exactly this reason. AHRQ PMC



What patients (and clinicians) feel when info slips


The ripple effects are familiar:

  • Diagnostic delays. A missing detail can send teams down the wrong path or force repeat testing. The National Academies note diagnosis is a complex, collaborative process that depends on getting the right information to the right person at the right time. National Academies Press

  • Medication errors. Conflicting lists and unclear handoffs increase the chance of omissions, duplications, or interactions. The Joint Commission’s alert on handoffs calls this out as a preventable pattern. Joint Commission

  • Lower trust and adherence. When patients are confused, they’re less likely to follow care plans, which translates into avoidable complications—and more work for already stretched teams. Globally, WHO estimates around 1 in 10 hospitalized patients experience harm, and at least half of this harm is preventable—communication failures are a consistent contributor. World Health Organization_1 World Health Organization_2



What good communication looks like (and why it works)


The best-performing teams don’t rely on memory or heroic effort. They standardize:


1) Structured handoffs


Tools like SBAR (Situation, Background, Assessment, Recommendation) turn a vague handoff into a tight, predictable checklist. Everyone knows what comes next and what’s still unclear. AHRQ’s TeamSTEPPS program (updated in 2023) treats SBAR as a core skill because it reliably improves clarity across disciplines. AHRQ+2AHRQ+2


What it sounds like in practice


  • Situation: “Ms. Rivera, 68, post-op day 1, increasing shortness of breath.”

  • Background: “COPD, on 2L O₂ at baseline; new crackles; 500 mL positive since surgery.”

  • Assessment: “Concern for fluid overload vs. atelectasis.”

  • Recommendation: “Chest X-ray this morning, consider diuretics, respiratory therapy eval.”


2) Closed-loop communication


Say the plan, confirm it’s heard, and verify it happens. This is basic in high-reliability fields (aviation, nuclear) and just as powerful in hospitals. AHRQ’s handoff guidance emphasizes explicit confirmation to prevent silent assumptions. PSNet


3) Teach-back with patients and families


After explaining the plan, ask patients to repeat it in their own words. If it’s fuzzy, clarify on the spot. Evidence shows teach-back improves comprehension and adherence across diverse settings. AHRQPMC


4) Checklists for complex moments


Checklists don’t replace judgment—they free it up. The WHO Surgical Safety Checklist dramatically reduced deaths and complications across eight hospitals by making the “important but forgettable” steps impossible to miss. New England Journal of MedicinePubMed



A quick story (the kind we all recognize)


8:05 a.m. Night team hands off a patient with chest pain. “Cards saw her—likely GI,” someone mentions in passing. The ECG from 6 a.m. (read as “borderline”) never makes it into the day team’s summary.

11:40 a.m. The patient worsens. Day team repeats labs and imaging; pieces don’t add up.

12:10 p.m. A nurse flags the ECG in another system; a subtle change is now more obvious. Cardiology reevaluates—treatment changes; the patient stabilizes.


Nothing dramatic went “wrong”—but two small misses (an incomplete handoff and fragmented records) created a delay, more tests, more stress, and more risk than necessary. This is exactly what structured handoffs and standardized tools are built to prevent. PSNetJoint Commission



Make safer communication the default: a practical playbook


You don’t need a new IT system to reduce miscommunication this month. Start with what your team controls:

  1. Adopt SBAR on every handoff (and stick to it).Post the template at nurses’ stations, add it to sign-out notes, and start on time. The goal isn’t perfection—it’s consistency. AHRQ

  2. Standardize “must-mention” items.For each unit or clinic, create a short “always include” list (allergies, code status, indwelling devices, pending critical results, patient concerns). Put it on the handoff printout.

  3. Close the loop.Before leaving the bedside or closing a consult note, state the plan and confirm who will do what by when. If no one heard it, it didn’t happen. PSNet

  4. Use teach-back on the one thing that matters today.You don’t have to teach back everything—prioritize the riskiest instruction (insulin changes, anticoagulants, warning signs). Ask: “Just to be sure I was clear—how will you take this at home?” AHRQ

  5. Create a “handoff home” for key files.If your EHR is fragmented, make a unit-level norm: one place for the latest care plan and to-do list. Many teams use a shared note type or a simple standardized sign-out that everyone knows to check first.

  6. Run a 10-minute weekly debrief.Pick one near-miss or confusion point. Ask: “What failed? What will we try next week?” Small, frequent tweaks beat rare, big projects.



Why it’s worth the effort

Better communication isn’t just nicer; it’s safer and more efficient. When teams share a mental model:

  • Patients move faster to the right care (fewer delays, fewer repeat calls).

  • Workdays feel lighter (less rework, fewer “Did anyone…?” messages).

  • Risk drops (fewer medication problems, fewer missed orders).

  • Trust rises—for patients who finally feel heard, and for clinicians who finally feel aligned.

Global safety data remind us how much is at stake: harm affects roughly 1 in 10 hospitalized patients worldwide, and half of that harm is preventable. Clear, consistent communication is one of the highest-leverage fixes we have. World Health Organization



The bigger picture


Communication is the bridge between what we know and what we do. The science of patient safety—from SBAR and teach-back to surgical safety checklists—shows that making the right thing the easy thing pays off in fewer errors and better experiences for everyone involved. As care grows more complex, teams that standardize the basics will protect patients—and protect each other. AHRQ+1New England Journal of Medicine



Reference


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