LAUSR

Communication failures in healthcare can be catastrophic. Lost test results, delayed diagnoses, missing handover information: all can have serious impacts on the safety of care with tragic consequences for patients. Even seemingly trivial mishaps can result in disaster. For example, a young mother died after two referral letters were inadvertently addressed to number 16, rather than number 1b, on the road where she lived, meaning diagnosis and treatment of cancer was significantly delayed. Her ten-year survival at the initial point of referral was estimated as 92%. In another case, a patient died of a major haemorrhage during surgery after pre-prepared, cross-matched blood had been incorrectly sent back to the blood bank due a single character in the patient’s name being misspelled. These cases, and many others, point to one of the most insidious risks associated with communication in healthcare: many communicative processes are still commonly viewed as rather mundane administrative tasks – instead of safety-critical processes that are essential to safe care. The lack of attention that is paid to the reliability of some communication processes has recently been revealed on a dramatic scale, with the publication of an investigation into the major failures affecting the handling of clinical correspondence in the National Health Service. A backlog of 709,000 items were found to have accumulated over several years in storage rooms and archives operated by National Health Service Shared Business Services, and to date almost 1800 patients have been identified who may have suffered potential harm. Across healthcare, a variety of sophisticated work is being done to understand and improve the reliability of many communication systems – such as the handling of test results, the transfer of clinical information and patient handover processes. But this massive communication breakdown in the handling of clinical correspondence, along with many other events, indicates that something far more fundamental needs addressing right across our healthcare systems: the hidden assumptions that people hold about what constitutes a reliable communicative process and what safe communication looks like. These assumptions influence both the behaviour of health professionals and the design and implementation of communication processes and can lie at the heart of why communication systems so often breakdown.