Common pitfalls and tips for better team communication

Introduction

An improperly completed drug order, optimal patient care not provided, confusion between what medicine has to be given to a dog, the wrong animal prepared for surgery, or an incorrect dose calculated for an in-patient, are all undesirable events that have a common root cause: a communication error. Such mistakes within a team can be the cause of all sorts of incidents, some of which may not be serious, but nevertheless create tension within the team, whilst others are dramatic and can even lead to the avoidable death of a patient. In high-risk industries such as aviation and nuclear power, where the link between communication and safety has long been established, communication has been codified by a set of rules that ensures a common language and secure exchanges to limit errors. The aim of this article is to introduce a few simple rules for safe communication that can be implemented within the practice team to limit errors and guarantee safe care for our patients. It is not easy to give up the communication shortcuts we have been using for a long time, but by bearing in mind the associated risks they create, it is easier to make the change. 

Communication errors and safe veterinary care 

While the association between communication and customer satisfaction has been studied for a long time, the link between communication and veterinary patient safety has only been studied recently. The first paper to highlight the role of soft skills, including communication, as a cause of errors in veterinary medicine was published in 2015 1. Other studies have followed 2,3, highlighting poor communication as a contributing factor in adverse events, and all the more so when the team is a complex one; this may be in terms of size, or where a hospital has many multi-disciplinary streams, or where there are a lot of part-timers – all of which increase the number of transmissions between individuals. A recent paper has shown that communication failures within the team, or between the team and another establishment (e.g., laboratory, referral hospital) contribute to 40% of professional negligence claims against canine veterinary surgeons 4. Securing excellent internal communications is, therefore, a key factor in healthcare safety, so how do we go about it? 

6 Sources for communication error

First and foremost, it is important to understand the potential sources for errors, in order to know how to avoid them. It is easy to think that a communication error comes either from the sender, who has made a mistake in what they said, or from the receiver, who has misunderstood what was said. However, if we break down the cognitive tasks that take place during a simple request, it becomes apparent that an error can have six different origins (Figure 1).

The sender of the message may be mistaken:

• in what they wish to do: for example, miscalculating a drug dose, or incorrectly assessing the additional examination to be prescribed;
• in the request they make: for example, the veterinarian asks their colleague to give morphine to a cat hospitalized after a road accident. He tells them the dose, but does not think to specify that he wanted the morphine added to the infusion, rather than given as a bolus; 
• in the words used for their request; in other words, the traditional “slip of the tongue” where one thing is said but another is meant, as in Example 1. 

Collate the exchanges in the communication loop

Usually, when we are asked to do something, we close the communication loop with a “yes,” an “okay,” a nod of the head, or simply by going straight to the action. This does not allow us to detect if an error has crept in between the transmission or understanding of the message. A simple and effective alternative for checking this, and if necessary, recovering it, is the “read-back.” This method, which originated in aeronautics, involves the receiver repeating all or part of the transmitted message. The sender then closes the communication loop by validating, correcting, or completing the message (Figure 2). This way of doing things may seem unnatural or even a little robotic, but it is simply a question of habit, and once acquired it saves a lot of time and avoids many mistakes.

The “two-speed brain”

Neuroscience studies show that our brain operates under two different systems and at two speeds: “system 1,” which is fast, instinctive and emotional, and “system 2,” which is slow, reflective and logical. By default, system 1 guides us 95% of the time, allowing the brain to save energy by simplifying complex tasks using shortcuts and automatisms. When the intuitions of “system 1” do not allow us to solve more complex problems, we have to switch to analytical reasoning using “system 2.” But this does not happen automatically, and the brain can remain in “routine” mode due to human factors such as stress, fatigue, or dehydration. So although we work in a complex profession that requires concentration and attention, we perform many tasks automatically: preparing a syringe of medicine, putting in an infusion line, completing an order, carrying out a clinical examination, neutering a cat, etc. With experience, these actions and gestures that are frequently repeated become part of our “system 1.” So in Example 2, the receiver of the message acts on “automatic pilot” under this system. Having prepared three anesthetics using the same protocol, she automatically prepares the fourth using the same protocol. Assuming the sender has given the right instructions, it is possible that, by selective listening, the receiver does not even hear that alfaxalone was specified and not propofol, even though the two words do not sound the same. 

In addition to collation, which enables the sender to detect a lack of understanding on the part of the receiver, the challenge when faced with important information or a change in the routine is to get the other person to switch from system 1, which is quick and intuitive, to system 2, which is slower and more reflective. To do this it is important to give explicit notice of the change, often before giving new instructions; this could be done by naming the contact, using a catchphrase such as “heads up,” and expressing what one is not going to do. For example, in Example 2, instead of simply saying “1.8 mL alfaxalone,” you could say “Heads up Marie, this time we’re not using propofol but alfaxalone.” 

Be precise in your message 

It is normal to adopt different ways of acting and communicating; that’s what corporate culture is all about. However, when implicit rules are not shared by everyone, they can be the source of errors (Example 3).

To avoid any risk, a number must always be accompanied by its unit. If the sender does not specify the unit themselves, or if in doubt, do not hesitate to ask them to specify. 

In addition, languages are full of oddities, abuses and facile expressions which can lead to communication errors. For example, “I’d like to drink a glass” (a word expressing a concept that is linked to it by an implied relationship, known as metonymy), or “he’s a bit of an Einstein” (the use of a proper noun or brand name to designate an object, known as antonomasia). Your clinic team is also likely to do this on a daily basis without even being aware of it. Some examples are; “prepare the TPLO for me,” “has the FUS cat eaten yet?”, “give the dog his corticosteroids,” “we’re going to put the cat to sleep” and even using a specific trade name for a drug on an invoice when the clinic has been using a generic version for the last two years. Designating a patient by species, breed and/or color, pathology or even the operation they have undergone or are about to undergo, referring to a medicine by its original name, an abbreviation of its active ingredient, or even another product with the same active ingredient, are all approximations classically observed in veterinary clinics, and which can sometimes lead to serious consequences (Example 4). 

The use of certain imprecise verbs with multiple meanings, such as give, do, make, or put, can also be the source of errors (Example 5). It is, therefore, important to accurately characterize the medicines we use, the action we wish to take, and the patient we wish to treat, in order to ensure that there is no misinterpretation by the person we are talking to. 

Identify the recipient of your message

Finally, as well as being precise with words and figures, it is important to be precise with the person to whom you are sending your message (Example 6). 

Such situations are commonplace in veterinary clinics. It may be at best merely unpleasant, but they can sometimes lead to more serious consequences: a tumor mistakenly discarded because nobody took responsibility for submitting it to the laboratory, even though the clinician had requested that it be sent for analysis; the hospitalized cat which developed hyperthermia but went undetected because two colleagues thought the other was taking care of it; and so on. Conversely, when the recipient is not clearly identified, it is possible that tasks, from preparing orders to administration procedures, are duplicated. Naming the person you are addressing and waiting for them to confirm that they are taking care of the required task helps to avoid these situations. Writing things down (e.g., using hospital care sheets) is often a good way of ensuring that a job is actually being carried out by the right person. 

The author of this article declares that she has no conflict of interest with the subject in question.

Conclusion

Poor communication within the team is the source of many errors that are detrimental to our patients. Choose a point of attack (for example: refer to patients by their name, or stop using the verb “to do”) and try to stick to it. If possible, work in pairs, or ideally with the whole team, and correct each other. The best way to detect and correct an error is to collate your message and only close the communication loop once you are sure that the message has been properly understood. Avoiding innuendo, flagging up an unusual request or one that requires special attention, using precise verbs, accompanying a number with its unit, and naming the person to whom you are speaking, are all ways of ensuring that your communication is secure.

Further reading

• Cros J. Mieux communiquer entre soignants. Un enjeu majeur de sécurité : Guide de phraséologie médicale (1^re édition). Arnette Edition 2018 
• Kahneman D. Système 1/Système 2 : Les deux vitesses de la pensée. Flammarion 2012