R E S E A R C H R E P O R T

Communication Failures: An Insidious Contributor

to Medical Mishaps
Kathleen M. Sutcliffe, PhD, Elizabeth Lewton, PhD, MPH, and Marilynn M. Rosenthal, PhD
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ABSTRACT

Purpose. To describe how communication failures con-
tribute to many medical mishaps.
Method. In late 1999, a sample of 26 residents stratified
by medical specialty, year of residency, and gender was
randomly selected from a population of 85 residents at a
600-bed U.S. teaching hospital. The study design in-
volved semistructured face-to-face interviews with the
residents about their routine work environments and
activities, the medical mishaps in which they recently had
been involved, and a description of both the individual
and organizational contributory factors. The themes re-
ported here emerged from inductive analyses of the data.
Results. Residents reported a total of 70 mishap inci-
dents. Aspects of “communication” and “patient manage-
ment” were the two most commonly cited contributing
factors. Residents described themselves as embedded in a
complex network of relationships, playing a pivotal role in
patient management vis-à-vis other medical staff and
health care providers from within the hospital and from
the community. Recurring patterns of communication
difficulties occur within these relationships and appear to
be associated with the occurrence of medical mishaps.
Conclusion. The occurrence of everyday medical mis-
haps in this study is associated with faulty communica-
tion; but, poor communication is not simply the result of
poor transmission or exchange of information. Commu-
nication failures are far more complex and relate to
hierarchical differences, concerns with upward influence,
conflicting roles and role ambiguity, and interpersonal
power and conflict. A clearer understanding of these
dynamics highlights possibilities for appropriate interven-
tions in medical education and in health care organiza-
tions aimed at improving patient safety.
Acad Med. 2004;79:186 –194.

Medical mishaps are a pervasive prob-
lem in health care organizations. In
2000, the Institute of Medicine (IOM)1
reported that between 44,000 and
98,000 people die every year in U.S.
hospitals because of medical errors. The
Dr. Sutcliffe is associate professor of organizational
behavior and human resource management, Univer-
sity of Michigan Business School, Ann Arbor, Mich-
igan. At the time of this study, Dr. Lewton was a
research associate in the University of Michigan Busi-
ness School. Dr. Rosenthal is professor emerita of
sociology and currently adjunct professor in internal
medicine, University of Michigan Medical School,
Ann Arbor, Michigan.
Correspondence and requests for reprints should be
addressed to Dr. Sutcliffe, University of Michigan
Business School, 701 Tappan, Ann Arbor, MI
48109-1234; telephone: (734) 764-2312; e-mail:
具ksutclif@umich.edu典.
studies on which the IOM relied for its
estimates,2 as well as other studies of
medical error,3,4 were based on physi-
cians’ reviews of medical records and
their judgments of adverse events. Stud-
ies in this vein tend to focus on the
incidence and nature of errors in medi-
cine and consider errors a function of
deficiencies in expertise and training.
What is missing from current research is
a rich description of the way clinicians
in complex organizations such as hospi-
tals experience errors in the context of
daily clinical practice.
To be sure, individuals make errors.
Yet, studies of organizational accidents
in other disciplines suggest that most of
the accidents that occur in complex
organizations do not usually have a sin-
gular cause, but result from a string of
latent flaws throughout the system.5,6
The growing interests in the broader
context of medical mishaps and the sys-
tems in which health care providers are
embedded comes at a time when the
conceptual and methodological tools in
current use drastically underestimate
the role of social, relational, and orga-
nizational factors in the generation of
adverse medical events.5– 8 With these
issues in mind, we undertook this qual-
itative study to examine the individual
resident’s experience and perception of
the causes and contexts of medical mis-
haps. Using data collected through a
series of 26 semistructured interviews

186 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004

with residents regarding their routine
work environments and the medical
mishaps with which they had been in-
volved, we explored how communica-
tion plays an integral role in many un-
toward events.
Faulty communication has been im-
plicated both in exhaustively studied
and well-known catastrophes such as
the explosion of the space shuttle Chal-
lenger,6,9 the release of methocyanate in
Bhopal, India,6 and in the occurrence of
adverse events in other high-risk con-
texts.10,11 Communication failures are
increasingly being implicated as impor-
tant latent factors influencing patient
safety in hospitals as well.10,12 A retro-
spective Australian survey of hospital
admissions showed that communication
problems were the most common cause
of preventable disability or death.13
More recently, Chassin and Becher12
analyzed how it was possible for the
wrong patient to undergo an invasive
procedure and concluded that “frighten-
ingly poor communication” was a key
causal element.
Today, medical care involves shorter
hospital stays with a rapid turnover of
acutely ill patients. Patient manage-
ment involves complex investigation
and coordination of care by a myriad of
medical specialists. Clinical medicine
thus involves multiple handoffs with
many places where critical information
must be effectively communicated. In
addition to the horizontal differentia-
tion of labor, vertical divisions of hier-
archy and power operate as well.14
Complex systems are made up of indi-
viduals at different hierarchical levels
who must constantly interrelate. These
relationships are shaped by the relative
status of those involved. These struc-
tures can have a powerful influence on
whether and how critical information is
effectively communicated. With this
theoretical framework in mind, in this
study we sought to understand how so-
cial, relational, and organizational
structures contribute to communication
failures that have been implicated as a
ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
large contributor to adverse clinical
events and outcomes.
METHOD
Study Location and Sample
The research site was a 600-bed U.S.
teaching hospital with a large graduate
medical education program. Our focus
was on the inpatient setting. The study
was approved by our university human
subjects’ committee, and the hospital’s
Internal Review Board, Quality com-
mittee, and department of risk manage-
ment.
The sample, stratified by specialty,
year of residency, and gender, was ran-
domly drawn from a total population of
85 residents within the three specialty
residency programs sponsored by the
hospital: Surgery, Medicine, and Ob-
stetrics/Gynecology (Ob/Gyn). Al-
though the research site was chosen for
convenience, we chose to randomly
sample residents to more accurately rep-
resent the total population.
The final sample consisted of 26 res-
idents (30% of the population) includ-
ing five surgery, 17 medicine (11 medi-
cine and six preliminary/transitional),
and four Ob/Gyn residents. Fourteen
were men and 12 were women. Eleven
residents were in their first year of post-
graduate training, five in their second
year, seven in their third year, two in
their fourth year, and one in their fifth
year. The disproportionate number of
first-year residents in the sample and
population was the result of students
going on to residencies in other pro-
grams after completing the first year.
Residents ranged in age from 25–39
years and averaged 29.8 years.
Data Collection and Analysis
We contacted individuals first by letter
and then by telephone. We collected
data using a semistructured interview
approach that allowed residents to re-
spond to themes generated from the
literature and incorporated into the in-
terview questions, and also enabled
them to reflect on their own unique
experiences. Before the interview, re-
spondents were assured of confidential-
ity and anonymity. Each person signed
and returned a confidentiality and vol-
untary participation agreement and
gave us permission to audiotape the in-
terview.
The interview protocol consisted of a
series of open-ended questions that fo-
cused on the general work environment
and the medical mishaps in which each
respondent had been involved within
the preceding three months. Many
terms have been used to describe medi-
cal errors but we chose to use the term
mishap, a neutral, nonjudgmental term
that encompasses a wide range of mis-
takes from the near-miss to a serious
iatrogenic injury, to elicit a broad range
of incidents. We asked respondents to
describe each mishap in depth and sub-
sequently asked them to categorize each
mishap into one or more of six catego-
ries (e.g., omission, commission, diagno-
sis, treatment, medication, or patient
management), which we derived from
review of existing literature on medical
mistakes. We then asked each respon-
dent to describe and categorize the con-
tributory factors associated with each
mishap (i.e., elements they thought
were linked with the mishap) and to
choose the most important factor. We
asked additional questions about resi-
dents’ work environments and daily activ-
ities, how mishaps were acknowledged,
and ended with a question about how
mishaps could be avoided. Interviews
lasted between one to two hours. All in-
terviews were tape-recorded, transcribed,
and assigned a unique record number.
Data were analyzed using case analy-
sis techniques suggested by Yin15 that
included putting information into dif-
ferent arrays, creating a matrix of cate-
gories and placing evidence within
these categories, tabulating the fre-
187
quency of different events, and conduct-
ing an iterative process to build an ex-
planation. Transcribed interviews were
entered into a qualitative data computer
program to facilitate coding and sorting
of interview data and to compile simple
counts and statistics once data had been
coded. Initial codes were derived from
the interview questions and the litera-
ture search (see previous paragraph for
an example of the six categories for
classifying each mishap), or were in-
duced from the narratives. For example,
after reviewing all responses to the ques-
tion “how was the mishap acknowl-
edged,” we found that the answers could
be sorted into one of five categories:
discussion, written documentation, re-
view at conference, ignored, or un-
known. Two researchers coded and
sorted interview data into the catego-
ries. The two coders agreed in 80% of
the cases and all disagreements were
resolved through discussion. In addition
to the categorical data coding, two re-
searchers read through the interview
transcripts repeatedly and then dis-
cussed them to induce the set of emerg-
ing themes and patterns and build an
explanation.
RESULTS
Overview
Respondents reported a total of 70 mis-
haps, which varied from relatively mi-
nor incidents such as a near miss in
which two patients’ orders were
switched, but subsequently corrected by
a nurse, to relatively major incidents,
such as a chest tube inserted on the
wrong side. Outcomes ranged from no
untoward consequences to death. Re-
spondents categorized mishaps most fre-
quently as errors of patient management
(29), errors of omission (26), errors of
diagnosis (24), and treatment (24), and
commission (21). Surprisingly, there
were very few medication-related errors
(6), probably because this institution
has had a computerized order-entry sys-
188 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
tem in place for several years. (The total
of all categories exceeds 70 because res-
idents often categorized an incident
into more than one category. For exam-
ple, a case where a patient with cardiomy-
opathy was sent home from the emer-
gency department with a pneumonia
diagnosis was categorized as omission, di-
agnosis, and patient management.)
Practitioner’s knowledge (30) and
communication (28) were cited most
frequently as the most important factors
that contributed to each mishap dis-
cussed. On the surface, practitioner’s
knowledge seems to refer to the extent
to which a practitioner’s medical
knowledge is complete and accurate; yet
further content analyses showed that
this category was more often used to
refer to a practitioner’s awareness of
certain pertinent information. For ex-
ample, residents chose this category for
information regarding a patient’s test
results, previous diagnoses/treatments,
or other medical historical issues that
were not communicated effectively to
the practitioner. Thus, we counted in-
stances of lack of information as in-
stances of faulty communication. We
found other contributory factors that
involved issues of communication/infor-
mation transmission as well, including
factors related to the specific situation
(e.g., busy emergency department), work
environment (hostile superior), and prac-
titioners’ interpersonal skills. In total,
communication failures of one kind or
another were an associated or contribu-
tory factor in 64 mishaps (91%).
The narratives themselves reveal ad-
ditional insight. In reflecting on their
roles within the hospital, residents de-
scribed themselves as embedded in a
complex network of relationships. The
resident plays a pivotal role in patient
care and management, vis-à-vis other
medical staff and administrators within
the hospital as well as community med-
ical practitioners. Although our qualita-
tive analysis suggests that poor transmis-
sion and exchange of information
accounts for some mishaps, this is only
part of the story. Other aspects of faulty
communication repeatedly show up
within the context of four key relation-
ships and provide a framework for un-
derstanding how issues of miscommuni-
cation can contribute to many medical
mishaps. Representative quotes from
the interviews are presented in Table 1.
These and other quotes are discussed
more fully below.
Relational Dyads and Common
Communication Failures
Residents and attendings. Faulty
communication typically arises in the
context of the relationship between a
resident and the attending physician
with whom the resident works.16 Sev-
eral themes are prominent. The attend-
ing is both a supervisor and a teacher,
whereas the resident performs the bulk
of patient care and decision making. We
found that residents in our study were
concerned about appearing incompe-
tent in front of those with more power
and they were hesitant to communicate
information that was unfavorable or
negative to themselves. A resident does
not want to appear ignorant about a
patient. He or she wants to appear
knowledgeable about the medical con-
dition and about the patient in particu-
lar, and to present pertinent but not
unnecessary information.
In our study, the hesitancy to com-
municate information to superiors was
evident in situations where a resident
did not want to appear incompetent and
also in situations where residents
thought they may offend those in
power. Residents repeatedly commented
on their hesitancy to call an attending
in the middle of the night. Although it
is considered appropriate under certain
conditions, unnecessarily waking or
bothering an attending is bound to
cause some anxiety and even some fric-
tion. There is a tension between want-
ing to be sure one is taking the correct
Table 1

Narratives from Interviews with 26 Residents about Medical Mishaps at a U.S. Teaching Hospital, Classified by Dyads and Communication Themes,
1999 –2000

Communication Theme

Dyad Hierarchy/Power/Social Structure Lack of Information Mode of Communication/Misinterpretation

Residents/attendings
“There has to be free communication
between the attending physician and the
supervising resident and the interns. . ..
You can’t be afraid to or ashamed to ask
for help.”
“. . .the nurses will not take a patient unless “I like to do everything face to face if I
they’ve gotten a report. . .but doctors can. It’s a convoluted system here.
simply don’t do that. They transfer patients, And I think the more you communicate
they do this, they do that and then they the better off you’ll be. You’ll improve
just don’t tell you.” patient care.”

Residents/community physicians “The lack of communication between the
outpatient setting and the office to the
hospital, it is a huge thing. A lot of time
when stuff happens I think it’s always a
lack of communication between
physicians or a disagreement about
what’s the correct course of action.”
“I was uncomfortable because I didn’t really
know what to do with the patient. I had a
patient I didn’t have a whole lot of
information on. . .and I had a resident that
was irritated because he had gotten no
communication from the admitting
physician.”
“. . .the communication between our team
and [the community specialist] was
such that there must have been a
breakdown there in
misunderstanding. . .. You’ve got to get
the information through all those
points. . ..”

Medicine Residents/specialists
“. . .it’s wasting your time dealing with that “When a patient comes from the ER to the “So the information that the ER gave to
because [the emergency room (ER)] will floor the nurse always gets a complete me at 10:30 is now 12 hours old;
deny anything happened. . .. It’s basically report. But most of the time it’s doctors three additional studies have been
a futile attempt. . .. You’re not going to who are not very good about it. And obtained. All the results have been
accomplish anything. . ..” anything can happen and nobody ever phoned to a different person; it’s just a
knows. It’s ridiculous.” pain. . ., just like the telephone game
where you rehash the story time and
time again.”

Residents/nurses “[The nurse] felt that I was not adequately
addressing her concerns about the
patient. . .. She said she felt intimidated
by me.”
“I think my lack of communication with the
student nurse [contributed to the mishap].
I think if it had been a more experienced
nurse she wouldn’t have moved the patient.
However I could have communicated better
with her. I should have said something like
’don’t touch anything. I’ll be right back.’”
“It’s easier to communicate with the
nurses on a person-to-person basis
rather than just putting orders in. But
if you’re not there and you put labs
through in the morning. . ., it’s not
done unless you go up and ask them
what’s going on.”

action and wanting to know enough not
to have to contact the attending.
Residents’ concerns about offending
those in power combined with their
perceptions that powerful others would
not listen to them or hear their point of
view also discouraged residents in our
study from productively disagreeing
when they had a different point of view.
In one case, the attending physician
treated an elderly woman with a super-
ficial vein thrombosis with anticoagu-
lants. The resident vehemently dis-
agreed with this course of action, and
described why she did not openly object
to the treatment:
If I felt like I could actually communi-
cate with that group of attendings I
would have tried, but I didn’t feel like it
would be useful for me. And all it would
have done would be to inflame the rela-
tions between me and that attending and
the patient still would have ended up
getting [inappropriate treatment].
The patient had a massive retroperi-
toneal bleed, was transferred to the in-
tensive care, and survived with serious
complications. Although it is not clear
which course of action was best in this
case, closed lines of communication be-
tween the attending and the resident
may have impeded optimal patient care.
Another kind of miscommunication
between attending physicians and resi-
dents concerns the amount of infor-
mation communicated by superiors.
Specifically, residents perceived that at-
tendings provided far too little informa-
tion to the resident who would be caring
for a particular patient.

ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004 189

 As one resident said:
The nurses will not take a patient un-
less they’ve gotten a report. And they
are very strict about that. And you
know, doctors simply don’t do that.
They transfer patients, they do this,
they do that, and then they just don’t
tell you. They don’t tell the resident.
And, I mean, it’s a simple thing but,
you know, a five-minute discussion
about a patient that’s being admitted
or being transferred or whatever is
worth its weight in gold when some-
thing dreadful happens and I’m run-
ning down there and I don’t even
know how old the patient is or what
problems they have. They really need
to communicate better.
This type of situation occurred be-
tween residents and attending physi-
cians within the hospital, and also be-
tween residents and consulting
physicians from within the hospital and
from the larger community.
Hospital residents and community
physicians. Lack of information and/or
the ineffective communication of infor-
mation arising from the relationship be-
tween hospital residents and commu-
nity physicians were associated with
reported mishaps. This faulty communi-
cation occurred most often when the
hospital resident admitted a patient
who was previously under a community
physician’s care. At the hospital in
which we gathered our data, private
physicians may admit a patient whose
care is then taken over by the “academic
team” of staff physicians and residents.
During this complete transfer of patient
care, information about the patient is
often seriously or completely lacking.
As one resident described:
God, we get patients, we’re lucky if we
get any information when the patients
come into the hospital. About half the
time we don’t even know they’re com-
ing. They’ll just show up on the floor.
There’s a huge, huge potential for mis-
haps to occur that way . . . between the
admitting physician and the people
190 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
who are ultimately responsible for tak-
ing care of the patient in the hospital
right then.
Communication failures within this
relationship also arise out of role con-
flict and ambiguity. Occasionally, a pri-
vate community physician admits a pa-
tient to the academic team but then
maintains some role in the patient’s
care. In this context, disagreement
about patient care and management, as
well as miscommunication, are com-
mon. Friction may occur when the res-
ident and the community physician dis-
agree on patient care decisions, or
miscommunicate about patient manage-
ment.17,18 In one case related by a resi-
dent, a 30-year-old woman was admit-
ted by her private physician on a Friday
morning and was scheduled for mag-
netic resonance imaging (MRI) that af-
ternoon. Her physician suspected a dis-
section in the carotid artery. The
resident was aware of the MRI, but had
no other information about the patient
and did not suspect any particular diagno-
sis. The resident sent the patient home for
the weekend pending the MRI results and
was severely chastised by the private phy-
sician for doing so against his wishes. The
MRI results, which were discovered Mon-
day morning, confirmed dissection in the
carotid artery—a potentially serious con-
dition. The resident highlighted some ar-
eas of miscommunication:
Our suspicion of the pathology wasn’t
there because [the patient looked
healthy and we didn’t know what her
physician had in mind]. . . . So we
asked him [her physician] if we could
just get the MRI and then discharge
her for him to follow-up on the results.
And again, this is me communicating
through my intern and then my intern
talking to him. And it was fine, we got
the MRI and let her go. The commu-
nication between our team and, you
know, the specialist was such that
there must have been a break down in
understanding. And I’m wondering if
the intern didn’t misunderstand the
whole thing and maybe I didn’t explain
it enough to her, and again it’s that
whole A to B to C to D. You’ve got to
get the information through all those
points and there’s a break down. I
don’t know where it happened neces-
sarily. . . . It’s stressful on the residents
and the interns because we’re caught in
the middle. We can’t make our own
decisions, and yet the specialists come
along whenever they want. So we’re
either bugging them, you know, calling
them, or there’s a break down in com-
munication because it’s going from the
specialists usually to the intern to the
resident and the attending. It’s like [the
game] telephone, you know?
This case illustrates two communica-
tion issues. First, little information was
communicated to the resident who was
asked to carry out the plan of care (the
MRI). Second, the communication
links were so convoluted that any mes-
sages that were conveyed were misinter-
preted as they moved through all those
involved. In sum, insufficient informa-
tion, faulty exchanges of existing infor-
mation, or ambiguous and unclear infor-
mation seem to characterize incidents
involving hospital residents and com-
munity physicians. The poor communi-
cation often arises out of role conflict
and ambiguity—where the boundaries
between who has the authority for care
and who is responsible for care are un-
clear. Our evidence suggests that these
situations provide fertile ground for
mishaps.
Internal medicine residents and spe-
cialists. Faulty communication is perva-
sive in relationships between medicine
residents and the residents and/or at-
tendings in different specialties within
the hospital. Our analysis revealed some
reasons for this. Not surprisingly, the
timely and effective exchange of perti-
nent information was a prominent
theme, particularly between the emer-
gency department and internal medi-
cine, as one medicine resident noted:
 Once they called me from the ER on a
patient who came with congestive
heart failure. They didn’t mention that
the patient had EKG changes and ab-
normal heart enzymes. She was having
a heart attack but we were really super
super busy so we didn’t have a chance
to take a look at the patient until she
hit the floor and she was having a heart
attack. She was infarcting. And so
that’s communication. Communica-
tion’s the problem. When somebody’s
taking care of the patient, when the
patient’s transferred from a service to a
different service, there should be very
good communication for that so that
all the information is conveyed there.
In another case, a resident reported
her experience with a patient who had
just been admitted and transferred to
general medicine from the emergency
department with dangerously low blood
pressure. No one on the floor had been
notified of the patient’s condition be-
fore arrival. The resident to whom the
patient was assigned just happened to
walk by the room when the patient
started to decompensate:
As I walked in, the patient was in
relative distress, short of breath, looked
sick. And so I asked them to take a
blood pressure immediately and the
blood pressure was in the seventies
over doppler. So I immediately put the
patient in Trendelenburg and got some
IV fluids going and the patient looked
septic to me. And I had to send the
patient to the unit immediately. I
think that patient should have never
come to the [medicine] floor to begin
with. And when I look back, the nurs-
ing records show[ed] that the patient
had been hypotensive in the ER prior
to even coming up to the floor.
Fortunately, the outcome in this case
was good. The patient was moved to the
intensive care unit soon enough and
avoided any serious complications, as
the resident noted:
ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
We were lucky that we got to the
patient soon enough because had the
patient been sitting there, as it happens
at times, depending on how busy the
intern and resident are, and not [been]
assessed by anyone, I think we could
have had a bad outcome.
We noted earlier how the openness
and quality of communication suffers in
the presence of private concerns about
hierarchy and power. Communication is
distorted because of concerns about of-
fending the more powerful party, and
also because residents want to avoid
conflict or believe that their concern
will not be addressed. These issues sur-
face frequently in situations where resi-
dents interact with the attendings in
other departments, which is often re-
quired of them. For example, medicine
residents frequently admit patients sent
to them by emergency department at-
tendings. When problems arise, a resi-
dent may find it difficult and frustrating
to speak up, particularly to disagree,
with an unknown attending. Residents
feel uncomfortable in voicing their objec-
tions and perceive that even if they do,
they may not get a positive response. One
resident in our study described what hap-
pened when a resident disagreed with the
patient management prescribed by the
emergency department:
It’s kind of hard for them to accept
[disagreement] because they are at-
tendings and we are residents—a lower
level of the hierarchy. So it’s not that
nice—they don’t feel that good if they
get a call from the resident and they
are an attending and that “blah, blah,
blah happened and you guys misman-
aged that patient.”
There is evidence that role conflict
and contrasting core values between dif-
ferent kinds of physicians can influence
effective communication.10,17 These
tendencies are exacerbated by the fact
that very little direct (face-to-face)
communication occurs between primary
care physicians and specialist consult-
ants.18 In our analysis, these kinds of
struggles often led to patient manage-
ment problems. In one case, a cardiolo-
gist who was called to consult on a
patient put the patient on a medication.
The medicine attending took her off the
medication. The notes in the patient’s
record were unclear and there was no
verbal communication between the par-
ties. This led to a disagreement with
regard to patient management and the
resident felt stuck in the middle:
. . . I guess the attending that was on
our team had a different philosophy
than the cardiologist who would have
kept her on anticoagulants. And, . . .
you know, in his note [he] didn’t write
it down and never verbalized it to us. I
mean, just bad communication.
As this resident went on to explain,
much of the communication between
consultants and medicine attendings is
through written notes in the patient’s
record—a sometimes ineffective means
of communicating:
The charts are the primary means of
communication between a lot of differ-
ent people—the consultants, the in-
terns and everyone. It’s not necessarily
the best way because a lot of times you
can’t read the handwriting very well. A
lot of times something’s forgotten,
you’re just writing a quick note and
they forget to mention something.
Residents and nurses. The relation-
ship between residents and nurses is
critical in preventing medical mishaps.
Residents make most of the day-to-day
decisions about patient care and nurses
not only carry out many of the orders,
but also are in closest contact with the
patient and are better informed about
their moment-by-moment condition.
Information given to nurses by residents
in the form of orders, and information
given to residents by nurses in the form
of the patient’s condition are crucial. Our
analysis revealed why both kinds of in-
formation may not be communicated
effectively.
191
 Residents routinely communicate or-
ders in hospitals by writing or typing the
orders in the patient’s medical record.
Yet, written communication, an imper-
sonal medium with limited capacity for
timely feedback,19 is seldom the most
effective way to communicate a plan of
action, especially when action needs to
be taken quickly. As one resident noted:
I think the main important thing is
communication with the nurses. Put-
ting orders in the computer or just
putting orders in the chart can be
missed and they have been missed be-
fore just because people don’t look at
it. And if you don’t tell the nurse on
the floor that “this is going to be or-
dered, watch for it,” like that, it may
take them a couple hours to go and get
the order from the clerk and do the
appropriate work. And I’ve seen it
more than not that that happens—that
orders get missed. And just recently
there was a chemo treatment order
that was missed. It was in the chart
early in the morning and it was missed
until three o’clock in the afternoon.
And I was asking, “Where’s the treat-
ment?” and they looked in the chart
and said, “Oh nothing was started”
because the attending never flagged
the chart or didn’t tell any of the
nurses, so no one looked at it. And
then when I was called by the attend-
ing in the afternoon [to check] that the
chemo started, I asked the nurses and
they said no. But there was no nurse to
run the chemo at night. So it got delayed
until the next morning. That could have
been avoided by communication.
Here the delay in treatment occurred
without adverse effects, but this type of
miscommunication could result in more
serious consequences.
Another resident gave a similar opin-
ion and also noted the importance of
face-to-face interactions:
I think that communication, especially
between the doctors and the nurses
who are giving the stuff that you’re
ordering, is very key. And I’ve had a lot
of positive feedback from the nursing
192 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
staff that “We appreciate you coming
down and telling us this so that it
doesn’t sit around for three hours and
the patient doesn’t get their nitroglyc-
erine that they need.” Or whatever.
The personal characteristics of com-
municators also can influence the char-
acter of a communication relationship,
sometimes giving rise to interpersonal
conflict.19,20 For example, in one case
the resident made a mistake in writing a
blood pressure medication prescription
for his patient. The nurse noticed this
and mentioned it right away, but not in
such a way that the resident understood
and/or responded. The nurse mentioned
it again only after the incorrect dosage
was administered:
The nurse had questions and did bring
it to my attention, but after the medi-
cine had been given. Now she said that
she had asked me as well before she
gave it. But she certainly asked me in a
much different way after she gave it. So
she could have come to me and been a
little bit more forceful about how it
didn’t make sense.
The nonverbal information displayed
by one or the other party (communi-
cated through eye gaze, posture, facial
expression, and voice tone) can also
influence communication,21 and our
data reflect this. For example, several
residents suggested that whether the
nurse was “nice” or “aggressive” could
make a difference in how an intern
responded to a nurse’s concerns regard-
ing a patient.
Although personal characteristics
may matter, we repeatedly found that
communication behaviors are influ-
enced by hierarchy and social structure
and, as described below, perceptions
that a superior is receptive to receiving
information. For example, as one resi-
dent related, a 70-year-old-patient who
had recently had cardiac bypass surgery
was not urinating and had low blood
pressure during the night following
surgery:
There was a communication problem
between the nurse who was taking care
of her and myself in that she felt that I
was not adequately addressing her con-
cerns about the patient, so she didn’t
call me back to say that the patient was
continuing not to do well . . . I don’t
understand. She said she felt intimi-
dated by me or something. It really didn’t
make a lot of sense to me at the time. . . .
We actually sat down and had a discus-
sion about this after—with the attending
physician and the nurse and myself—
about how this had transpired and what
had happened. And so that’s how I had
some insight into her perspective on it.
And basically she felt that . . . I was
blowing her off or didn’t seem to be
approachable and therefore for some rea-
son she felt it was appropriate just not to
do anything until the next day.
Although the surgery resident was
not certain of the eventual outcome
because the patient was transferred to
another unit, he reported that there
were “potential long-term complica-
tions” for the patient due to this mishap.
In the following excerpt from an in-
terview, a resident explained the diffi-
cult position nurses often find them-
selves in.
Resident: In some cases nurses can
be reluctant to question physicians
because, you know, because of physi-
cians’ responses to them, questioning
them, or residents for that matter.
Primary investigator: You mean
they have a sense that they [physi-
cians] don’t welcome criticism, any
questioning?
Resident: Right. So I think this
demonstrates that it’s very important
that nurses feel able to question the
doctors...they walk a fine line because
they don’t always know what’s appro-
priate to question and what’s not ap-
propriate to question. . . .
DISCUSSION
Our qualitative study provides insight
into the insidiousness of faulty commu-
nication as a contributor to medical
mishaps. The residents in our study per-
ceived that communication difficulties
played a role in the vast majority of the
medical mishaps they experienced. Our
findings are consistent with other re-
search showing a strong link between
poor communication, and errors and ad-
verse events.12,13 Although few studies
in medicine have systematically exam-
ined this association, the implications
drawn from a variety of sources1,5,10,11
are that faulty communication is wide-
spread and results in a number of unto-
ward consequences for patients, caregiv-
ers, and the organizations in which they
are embedded.
A key finding of our study is that
failures of communication are not sim-
ply the result of faulty transmission and
exchange of information. This is not to
underestimate the extent to which poor
communication results from inadequate
information sharing among interdepen-
dent caregivers. Certainly our data show
that in some relational contexts too
little information is communicated, is
not timely, or is not communicated us-
ing a medium appropriate for the mes-
sage or task. Yet, our findings show that
there is more to it than this mechanistic
view of communication suggests. Our
findings are consistent with studies in
organizational communication21–25 that
show that communication failures arise
from vertical hierarchical differences,
concerns with upward influence, role
conflict and ambiguity, and struggles
with interpersonal power and conflict.
Communication is likely to be dis-
torted or withheld in situations where
there are hierarchical (e.g., power/sta-
tus) differences between two communi-
cators,22 particularly when one party is
concerned about appearing incompe-
tent, does not want to offend the other,
or when one party perceives that the
other is not open to communication.25
These situations are most likely to occur
in relationships between residents and
attendings, medicine residents and
other specialties, and also between res-
ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
idents and nurses. Communication dif-
ficulties also arise in situations where
there are role conflict and ambigu-
ity,21,23,24 often in the relational con-
text between hospital and community
physicians. Finally, the character of
communication is sometimes a conse-
quence of personal differences and the
interpersonal conflicts that arise from
these differences,25 and often occur be-
tween residents and nurses.
In sum, barriers to effective commu-
nication are both individual (for exam-
ple communication is impaired when
people are busy or fatigued), and sys-
temic. Communication behaviors are
embedded in the structure of the orga-
nization and reside in the socially struc-
tured and culturally patterned behavior
of groups (i.e., subunits, specialties, de-
partments) and practices of the institu-
tion.19,21,22,25 Although individuals may
decide for themselves how they want to
communicate, their behavior is likely to
be constrained by the norms of their
particular professional subculture.16
Consequently, remedies must be tar-
geted toward multiple levels: It is going
to take more than simply changing
one’s individual-level actions to make a
difference in the system. Actions need
to be taken at the level of the group,
subunit and organization. A clearer un-
derstanding of the underlying dynamics
revealed in this study highlight possibil-
ities for future research as well as appro-
priate interventions both in medical ed-
ucation and in health care organizations
themselves.
Our study focused on the inpatient
setting. Yet, care is frequently delivered
in the outpatient setting. One avenue
for future research is to examine
whether the factors and dynamics found
here are similar to the dynamics that
occur in the outpatient setting. A sec-
ond avenue of future research is to in-
vestigate the determinants of caregivers’
communication choices. To our knowl-
edge, little attention in medical educa-
tion research has been paid to the idea
of matching the communication me-
dium to the message. Yet, evidence sug-
gests that the mode of communication
often determines the outcomes of a
task.19,26
One recommendation for improving
systemic communication comes from
studies of adverse events in high risk
settings which resemble health care
contexts (e.g., aircraft carrier flight op-
erations and wildland firefighting); set-
tings where there is huge variability in
circumstances, the need to adapt pro-
cesses quickly, a quickly changing
knowledge base, and highly trained pro-
fessionals who must use expert judg-
ment in dynamic settings.1,27 Consis-
tent with the results presented here,
other studies have shown that commu-
nication failures are important contrib-
utors to adverse events in other con-
texts. One suggestion for improving
communication in these circumstances
is to enact a five-part briefing protocol
(STICC) that is being used by the U.S.
Forest Service to give direction to fire
fighters:28
䡲 Situation: Here’s what I think we
face;
䡲 Task: Here’s what I think we should
do;
䡲 Intent: Here’s why;
䡲 Concern: Here’s what we should keep
our eye on;
䡲 Calibrate: Now talk to me. Tell me if
you don’t understand, cannot do it, or
see something I do not.
Just as clinical practice guidelines can
assist practitioners in making decisions
and taking actions for specific clinical
circumstances, communication practice
guidelines like the one noted above can
serve the same purpose.
This exploratory study has both
strengths and limitations. For example,
data from practicing health care provid-
ers are a rich and neglected source of
information about factors in their own
environment that might contribute to
error. Because mishaps arise out of a
complex interplay of human and orga-
193
nizational factors, a methodology is re-
quired that takes into account the ac-
tors’ understanding of the event. Self-
reports of critical incidents are
considered by many, including the avi-
ation industry,29 as the most viable
method to obtain comprehensive infor-
mation about an event, especially when
respondents consider a broad range of
factors.30 We sought to generate a rich
description of residents’ experiences and
the contexts in which they are embed-
ded to better understand the basic
mechanisms (the “why” and the “how”)
of error occurring in everyday organiza-
tional settings. We did not intend to
establish incidence rates or to establish
causality, and patterns that emerged in
the data are suggestive of associated
causes rather than definitive. We are
mindful that retrospective event histo-
ries are subject to perceptual biases,
poor recall, and poor or inaccurate ar-
ticulation that could have influenced
the results.
In conclusion, faulty communication
increasingly is being implicated in the
evolution of medical errors and adverse
events. And the proposed solution often
is to promote “better information trans-
fer.” This goal is hard to achieve for
clinicians in the best of circumstances,
but it is even more challenging for res-
idents who are caught in a web of com-
plex relationships. Moreover, communi-
cation failures entail more than the
faulty transfer of information. They are
a consequence of individual, relational,
and systemic factors, which suggests
that more effective communication is
more difficult than it looks. We were
surprised by the insidiousness of com-
munication failures as contributors to
the mishaps reported by our respon-
dents. However, our observations have
strong face validity and suggest that the
systemic problems of poor communica-
tion as latent precursors to medical mis-
haps should not be taken lightly.
This study was supported in part by a grant from
the University of Michigan Office of the Vice-
194 ACADEMIC MEDICINE, VOL. 79, NO. 2 / FEBRUARY 2004
President for Research. The authors are grateful to
Pat Cornett, Eric Eisenberg, Zach Lewton, Lexa
Murphy, Steve Schenkel, Tim Vogus, Bob Wears,
and Karl Weick for constructive comments on
previous drafts.
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