How In-Clinic Communication Affects Patient Safety

Communication is recognized as being central to the delivery of effective veterinary care.¹ Veterinary educational institutions have woven communication skills into already busy curricula.^2,3 Being a good communicator is considered among the key ingredients for being a good veterinarian,^4,5 and research shows the effect of communication on client experience and satisfaction.^6,7 Although how we communicate with clients greatly affects the care received by patients, communication continues to play a crucial role in care delivery far beyond the consulting room.

Interest in veterinary patient safety is growing.^8,9 Veterinary professionals all want to minimize the risk of causing harm to our patients while delivering care to the best of our ability. A critical determinant for the safety of the care our patients receive is communication between all members of the veterinary team, making improving team or in-clinic communication a key priority for delivering safer care.^10,11 Research is beginning to show the crucial role of team communication in veterinary practice.^12-14 Good communication helps the veterinary team keep patients safe and improves the practice environment and culture, a good thing given current recruitment and retention challenges in the veterinary profession.

Communication theory can be applied to team communication doing 3 jobs in practice: transferring information, creating shared understanding, and influencing team culture.^15-17 Using this framework of 3 communication jobs, this article provides practical examples for optimizing in-clinic communication to improve patient safety.

Information Transfer

Think about a normal day in practice. How many times do you have to pass information about a patient to another team member? With how many people working in different roles do you communicate? In how many different ways do you communicate? Critical information about patients is exchanged through numerous spoken conversations, including handovers, and in a wide range of written formats (e.g., hospital sheets, clinical notes, notice boards). Sometimes the message does not get through to the people who need it when they need it, thereby increasing the risk that the veterinary team may fail to do the right thing at the right time for patients. Common areas that may cause problems for patients include spoken prescribing, drug dispensing, and patient handovers.^13,14,18

Spoken Prescribing

Spoken prescribing (also called oral or verbal prescribing) is the practice of asking a colleague to administer medication to a patient,¹⁹ often in a noisy, busy environment with multiple distractions. Those involved in the exchange are often juggling multiple tasks, experiencing what would be described as a high cognitive load, which is not the best environment for avoiding mistakes. Written prescribing avoids many of those risks but is not always practical or possible.

With prescribing or administering instructions that must be spoken, the risks can be reduced by practicing closed-loop communication: specifying who we are talking to and which patient we are talking about. This well-known technique is used in several safety-critical industries in which the receiver (person hearing the spoken message or instruction) repeats or “calls back” the message to the sender or person delivering the message, who then verifies that the message has been transferred accurately.²⁰

Drug Dispensing

Another medical activity prone to error is dispensing drugs. Minimizing dispensing error often requires looking more widely at the systems that are currently in place. Where are drugs stored? Is the area well lit? Are the drugs easy to reach? Do drug names sound similar or look alike?²¹ Storing drugs with similar-sounding names or similar appearances close together increases the risk of the wrong drug being dispensed. Solutions include storage areas with good lighting and products that are easy to see (not hidden), clearly labeled, and stored within reach.

What about computer systems? Does your computer system have built-in prescribing safety functions? Solutions can include computer systems that prevent the generation of a drug label if a medication for a canine patient is accidentally dispensed for a feline patient.

Medications are also frequently double-checked, which involves a second person verifying that the number and type of tablets dispensed match the drug label, usually confirmed by countersigning (adding a second set of initials or signature) to the drug label. Double-checking can be done by 2 people at the same time; however, because of the obvious practical challenges in busy practice settings, the second check is often done later. Evidence for the effectiveness of double-checking is mixed.²² For example, confirmation bias means we are likely to assume that the first person checking has done the job correctly, which may reduce the thoroughness of a second check. It may therefore be just as safe to have 1 person check medication but reduce their cognitive load by ensuring that the environment helps make the job of medication checking as easy as possible (e.g., have enough time and not be rushed, be able to work in a well-lit and quiet environment with minimal interruptions) (BOX 1).

Patient Handovers

Handovers are defined as “the accurate transfer of information and patient responsibility,” and improving patient handovers in health care has been identified as a key priority for patient safety.²⁴ Handover applies to the transfer of patient care to people on different shifts, to external after-hours providers, and to referral practices.²⁵ As the delivery of veterinary care has advanced and become more complex, the number of interfaces requiring handover between individual practitioners has increased, thereby increasing the value of optimizing handovers in veterinary practice.^25,26

Multiple interfaces during handover increase the risk that a person receiving the information may misunderstand or not fully understand the patient’s needs. Poor handovers can lead to a variety of effects.²⁶ For example, a client may be asked the same questions twice if a piece of clinical history is not handed over. More critically, patient care can suffer. For example, failing to communicate a patient’s feeding preferences might hinder recovery, or failing to accurately describe changes in wounds or other injuries might complicate future treatment decisions.

However, more is not always better. Overly complicated, long, or detailed handovers may be just as much of a challenge to patient safety as those without enough detail if they cause confusion or take up too much time. A balanced approach provides enough but not too much detail.

By standardizing the information transferred at handover, a wide range of formalized tools have been created,²⁷ including SBAR (Situation, Background, Assessment, and Recommendation), which is recommended for use in veterinary practice (BOX 2).^26,28 SBAR is a guide for which content to include during the handover, how to structure the content, and how to perform a spoken handover. Despite the popularity of such structured tools, they have been criticized for ignoring the complex social dynamics around handovers; therefore, researchers caution against relying on them as the primary means for improving interprofessional communication.^29-31

Shared Understanding and Team Culture

Communication is more complex than simply the transfer of information. It is an interactional, social activity important for creating shared understanding between people and enabling effective coordination.^17,32 How we communicate with each other as a team (e.g., what we say, what we don’t say, how we say it) determines the culture we all experience,³³ which in turn affects our actions as we care for patients, thereby affecting the safety of our patients.

Situational Awareness

Team situational awareness is a valuable determinant of team performance. Defined as “the shared understanding of a situation among team members at 1 point in time,”³⁴ situational awareness plays a vital role in how veterinary teams manage the ever-changing flux of patient requirements, client needs, and resources available (e.g., staffing levels, available equipment). Shared awareness of the “state of play” enables teams to rework plans as the day unfolds (e.g., briefs, huddles, debriefs); when teams come together to plan the day, pause, reflect, and reset; and then at the end of the day when they capture lessons learned.³⁵ Tools that can be used to help develop and maintain shared awareness for teams to deliver care safely include white boards, checklists, and other memory aids.³⁶ Situational awareness is often lost during high-pressure, stressful moments. For example, efforts to stem a bleeding blood vessel during a surgical procedure may take a team member’s full attention, causing them to fail to notice and act on other critical issues (e.g., managing the patient’s anesthetic depth, completing a swab count at the end of the surgery).

Assertiveness Tools

The success of shared understanding and team culture depends on the extent to which all team members, regardless of role or perceived seniority, feel able to contribute.³⁷ Hierarchy within some veterinary teams poses a barrier to speaking up.^12,33  Similar to structured handover tools, graded assertiveness tools guide team members in how to verbally challenge the actions and behaviors of others.

One way to encourage step-wise progression in the level of assertiveness is PACE (Probe, Alert, Challenge, and Emergency/Escalate).³⁸ PACE can be used to challenge and pause or stop actions that might be unsafe or dangerous (e.g., challenging a colleague who does not want to recheck the position of an endotracheal tube of an anesthetized patient [BOX 3]). Although such tools can be useful in a given moment, they may not affect the team environment and culture long term and their use may be inhibited by poor team culture.

Psychological Safety

Flattening hierarchies and increasing speaking-up behavior require development of psychological safety, a climate in which team members feel safe to take interpersonal risks (e.g., ask questions, raise concerns, share ideas) without fearing negative consequences.³⁹ Higher levels of psychological safety are associated with improved team performance. An environment of psychological safety is increased in the presence of trust, safety to acknowledge and report mistakes, learning, and innovation.^40,41

Edmondson urges leaders to adopt 3 key strategies to help create psychological safety: framing the work, inviting participation while demonstrating fallibility, and welcoming messengers.³⁹ For veterinary leaders, that means emphasizing the uncertainty, complexity, and unpredictability of much of our work and expressing that no single person has all the answers and that therefore all contributions are needed and welcomed. Those behaviors are well encapsulated by the concept of inclusive leadership,⁴² connecting calls for increased diversity and inclusion with the creation of positive, collaborative team environments that support the delivery of safe patient care.

Levels of psychological safety affect the safety of care delivered. Lower levels of psychological safety mean mistakes are less likely to be pointed out, leading to increased risk that the mistake will reach the patient rather than being caught by the team. Team members are also less likely to ask for help and less able to coordinate effectively to execute complex tasks, such as resuscitation. In other words, care may be less safe when teams do not experience psychological safety.⁴³

Civility

Although the behavior of leaders is clearly crucial, the behavior of all team members also matters. Recent research has highlighted the significant negative consequences of incivility for veterinary teams.⁴⁴ Incivility has been defined as “low-intensity deviant (rude, discourteous) behaviour with ambiguous intent to harm the target in violation of workplace norms for mutual respect.”⁴⁵ Note that this is not about overt harassment and abuse but rather about more insidious, low-level actions such as eye-rolling, tutting, and/or ignoring and belittling others. It has been shown that such behaviors have wide-ranging negative effects on job satisfaction, wellbeing, and workplace performance. Incivility also directly reduces safety during care.⁴⁵ Research shows that those directly experiencing incivility and those witnessing it lose time worrying about the incivility, thereby reducing the quality of their work, and are more likely to take time off work, increasing workload pressure. Incivility leads team members to be less likely to help each other, which will also negatively affect the quality of the care they deliver. See civilitysaveslives.com for more information.

Solutions include appreciating that in a high-pressure, high-workload environment such as veterinary practice, no one is immune to behaving in unintended ways. The risk for uncivil behavior can be reduced by encouraging team members to prioritize self-care and by approaching episodes of incivility with curiosity and kindness. Development of a permissive environment in which unhealthy team behavior goes unchecked can be prevented by using coaching-style conversations to identify what a person might need to avoid such behavior in the future (i.e., “calling it out with kindness”).^46,47 Organizational-level support and frameworks assure team members of shared expectations with regard to behavioral standards and inform them that if those standards are not met, fair and consistent actions will be taken.

Summary

Despite animals being at the heart of veterinary care, veterinary practice is a person-centered business; how we communicate with, relate to, and treat each other really matters. Communication is crucial to transferring vital pieces of information amid increasingly complex teams and organizational structures. To create the shared mental models that allow team members to coordinate care safely and well, teams need to communicate effectively. Good team communication creates environments in which everyone feels they belong, are valued, and can contribute. Ultimately, supportive, inclusive environments will improve team wellbeing and the quality and safety of care.