Cited by 1,069Patient Safety and Medication ErrorsHospital Admissions and OutcomesClinical Reasoning and Diagnostic Skills

The DOI matches its Crossref record; 14 of the 14 references it cites were found in a registry or an index.

Communication Failures: An Insidious Contributor to Medical Mishaps

Sutcliffe, Kathleen M., Lewton, Elizabeth, Rosenthal, Marilynn M.·2004·Academic Medicine

DOI 10.1097/00001888-200402000-00019

Open this paper in CoChat — free account

Abstract

PURPOSE: To describe how communication failures contribute 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 involved 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 reported here emerged from inductive analyses of the data. RESULTS: Residents reported a total of 70 mishap incidents. Aspects of "communication" and "patient management" 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 mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication 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 interventions in medical education and in health care organizations aimed at improving patient safety.

Integrity signals

Registry

Crossref · 10.1097/00001888-200402000-00019

Cites

14 of 14 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Claims the paper makes

This paper’s full text isn’t openly available, so its claims and self-check weren’t run. The registry and citation checks still apply.

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Human error: models and management
Reason, J. (2000) · BMJ · doi:10.1136/bmj.320.7237.768 · Cited by 5,665
The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster
Weick, K. E. (1993) · Administrative Science Quarterly · doi:10.2307/2393339 · Cited by 5,000
The Quality in Australian Health Care Study
Wilson, R. M., Runciman, W. B., Gibberd, R. W., Harrison, B. T., Newby, L., & Hamilton, J. D. (1995) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.1995.tb124691.x · Cited by 2,480
Estimating Hospital Deaths Due to Medical Errors
Hayward, R. A., & Hofer, T. P. (2001) · JAMA · doi:10.1001/jama.286.4.415 · Cited by 586
The Reliability of Medical Record Review for Estimating Adverse Event Rates
Thomas, E. J., Lipsitz, S. R., Studdert, D. M., & Brennan, T. A. (2002) · Annals of Internal Medicine · doi:10.7326/0003-4819-136-11-200206040-00009 · Cited by 259
The Wrong Patient
Chassin, M. R., & Becher, E. C. (2002) · Annals of Internal Medicine · doi:10.7326/0003-4819-136-11-200206040-00012 · Cited by 249
The moral limits of Feinberg's liberalism
Doppelt, G. (1993) · Inquiry · doi:10.1080/00201749308602322 · Cited by 231
A Dual-Capacity Model of Communication Media Choice in Organizations
Sitkin, S. B., Sutcliffe, K. M., & Barrios-Choplin, J. R. (1992) · Human Communication Research · doi:10.1111/j.1468-2958.1992.tb00572.x · Cited by 221
Self-citation
Communication between primary care physicians and consultants
Epstein, R. M. (1995) · Archives of Family Medicine · doi:10.1001/archfami.4.5.403 · Cited by 145
How Good Is Communication Between Primary Care Physicians and Subspecialty Consultants?
McPhee, S. J. (1984) · Archives of Internal Medicine · doi:10.1001/archinte.1984.00350180209029 · Cited by 125

Show all 14 references

Research works printed but not linked: 2

Thomas, 1999, Inquiry, 36, 255
Duldt, 1981, Nurs Outlook, 29, 640

Sorted by citations

Items 201–300 of 1,000

Attitudes About Patient Safety: A Survey of Physicians-in-Training
Sorokin, R., Riggio, J. M., & Hwang, C. W. (2005) · American Journal of Medical Quality · doi:10.1177/1062860604274383 · Cited by 52
Clinical review: The hospital of the future - building intelligent environments to facilitate safe and effective acute care delivery
Pickering, B. W., Litell, J. M., Herasevich, V., & Gajic, O. (2012) · Critical Care · doi:10.1186/cc11142 · Cited by 52
Handoffs in Hospitals: A review of the literature on information exchange while transferring patient responsibility or control
Cohen, M. D., & Hilligoss, P. B. (2009) · Deep Blue (University of Michigan) · Cited by 50
Regrets Associated with Providing Healthcare: Qualitative Study of Experiences of Hospital-Based Physicians and Nurses
Courvoisier, D. S., Agoritsas, T., Perneger, T., Schmidt, R. E., & Cullati, S. (2011) · PLoS ONE · doi:10.1371/journal.pone.0023138 · Cited by 50
Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review
Rabøl, L. I., Østergaard, D., & Mogensen, T. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2009.037184 · Cited by 50
Perspectives on team communication challenges in caring for children with medical complexity
Adams, S. L., Beatty, M., Moore, C., Desai, A. D., Bartlett, L., Culbert, E., Cohen, E., Stinson, J., & Orkin, J. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06304-8 · Cited by 50
The limits of checklists: handoff and narrative thinking
Hilligoss, B., & Moffatt-Bruce, S. D. (2014) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-002705 · Cited by 48
Satisfaction of Intensive Care Unit Nurses With Nurse-Physician Communication
Manojlovich, M., & Antonakos, C. L. (2008) · JONA The Journal of Nursing Administration · doi:10.1097/01.nna.0000312769.19481.18 · Cited by 49
Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm
Wright, J., Lawton, R., O'Hara, J. K., Armitage, G., Sheard, L., Marsh, C., Grange, A., McEachan, R., Cocks, K., Hrisos, S., et al. (2016) · Programme Grants for Applied Research · doi:10.3310/pgfar04150 · Cited by 48
Complexities of emergency communication: clinicians’ perceptions of communication challenges in a trilingual emergency department
Pun, J., Chan, E. A., Murray, K. A., Slade, D., & Matthiessen, C. M. I. M. (2016) · Journal of Clinical Nursing · doi:10.1111/jocn.13699 · Cited by 48
The impact of nurse/physician collaboration on patient length of stay
Tschannen, D. J., & Kalisch, B. J. (2008) · Journal of Nursing Management · doi:10.1111/j.1365-2834.2008.00926.x · Cited by 48
Supporting Clinical Cognition: A Human-Centered Approach to a Novel ICU Information Visualization Dashboard.
Faiola, A. J., Srinivas, P., & Duke, J. D. (2015) · PubMed Central · Cited by 48
Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions
Sur, M. D., Schindler, N., Singh, P., Angelos, P., & Langerman, A. J. (2015) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2015.10.006 · Cited by 47
Effects of Physicians’ Information Giving on Patient Outcomes: a Systematic Review
Lie, H. C., Juvet, L. K., Street, R. L., Gulbrandsen, P., Mellblom, A. V., Brembo, E. A., Eide, H., Heyn, L. G., Saltveit, K. H., Strømme, H., et al. (2021) · Journal of General Internal Medicine · doi:10.1007/s11606-021-07044-5 · Cited by 47
Communication and psychological safety in veterans health administration work environments
Yanchus, N. J., Derickson, R., Moore, S. C., Bologna, D. A., & Osatuke, K. (2014) · Journal of Health Organization and Management · doi:10.1108/jhom-12-2012-0241 · Cited by 50
Patient safety education to change medical students' attitudes and sense of responsibility
Roh, H., Park, S. J., & Kim, T. (2015) · Medical Teacher · doi:10.3109/0142159x.2014.970988 · Cited by 46
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme
Neily, J. B., Mills, P. D., Lee, P. N., Carney, B., West, P., Percarpio, K. B., Mazzia, L. M., Paull, D. E., & Bagian, J. P. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2008.031005 · Cited by 46
Risk Managers, Physicians, and Disclosure of Harmful Medical Errors
Loren, D. J., Garbutt, J. M., Dunagan, W. C., Bommarito, K. M., Ebers, A. G., Levinson, W. S., Waterman, A. D., Fraser, V. J., Summy, E. A., & Gallagher, T. H. (2010) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(10)36018-1 · Cited by 46
Leading Clinical Handover Improvement
Clarke, C. M., & Persaud, D. D. (2011) · Journal of Patient Safety · doi:10.1097/pts.0b013e31820c98a8 · Cited by 46
Improving Nursing Students’ Communication Skills Using Crew Resource Management Strategies
Aebersold, M., Tschannen, D. J., & Sculli, G. L. (2013) · Journal of Nursing Education · doi:10.3928/01484834-20130205-01 · Cited by 45
“Excuse Me:” Teaching Interns to Speak Up
O'Connor, P. E., Byrne, D., O’Dea, A., McVeigh, T. P., & Kerin, M. J. (2013) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(13)39056-4 · Cited by 45
Measuring nursing benefits of an electronic medical record system: A scoping review
Jedwab, R. M., Chalmers, C., Dobroff, N. K., & Redley, B. (2019) · Collegian Journal of the Royal College of Nursing Australia · doi:10.1016/j.colegn.2019.01.003 · Cited by 53
Hospital Handoffs as Multifunctional Situated Routines: Implications for Researchers and Administrators
Hilligoss, B., & Cohen, M. D. (2011) · Advances in health care management · doi:10.1108/s1474-8231(2011)0000011008 · Cited by 47
Hospital patients' reports of medical errors and undesirable events in their health care
Davis, R. E., Sevdalis, N., Neale, G., Massey, R., & Vincent, C. A. (2012) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2012.01867.x · Cited by 44
Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues
Skjeggestad, E., Gerwing, J., & Gulbrandsen, P. (2017) · Patient Education and Counseling · doi:10.1016/j.pec.2017.03.007 · Cited by 44
Patient Safety: Effective Interdisciplinary Teamwork Through Simulation and Debriefing in the Neonatal ICU
Smith, J. R., & Cole, F. S. (2009) · Critical Care Nursing Clinics of North America · doi:10.1016/j.ccell.2009.01.006 · Cited by 44
Assessing system failures in operating rooms and intensive care units
van Beuzekom, M., Akerboom, S., & Boer, F. (2007) · BMJ Quality & Safety · doi:10.1136/qshc.2005.015446 · Cited by 44
Improving Shift Report Focus and Consistency With the Situation, Background, Assessment, Recommendation Protocol
Cornell, P. T., Townsend‐Gervis, M., Yates, L., & Vardaman, J. M. (2013) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0b013e31829d6303 · Cited by 43
Rethinking resident supervision to improve safety: From hierarchical to interprofessional models
Tamuz, M., Giardina, T. D., Thomas, E. J., Menon, S., & Singh, H. (2011) · Journal of Hospital Medicine · doi:10.1002/jhm.919 · Cited by 43
Beyond Paging: Building a Web-based Communication Tool for Nurses and Physicians
Locke, K. A., Duffey-Rosenstein, B., Lio, G. D., Morra, D. J., & Hariton, N. (2008) · Journal of General Internal Medicine · doi:10.1007/s11606-008-0827-2 · Cited by 43
Interprofessional communication with hospitalist and consultant physicians in general internal medicine: a qualitative study
Conn, L. G., Reeves, S., Dainty, K. N., Kenaszchuk, C., & Zwarenstein, M. (2012) · BMC Health Services Research · doi:10.1186/1472-6963-12-437 · Cited by 43
Violations of Behavioral Practices Revealed in Closed Claims Reviews
Griffen, F. D., Stephens, L. S., Alexander, J. B., Bailey, H. R., Maizel, S. E., Sutton, B. H., & Posner, K. L. (2008) · Annals of Surgery · doi:10.1097/sla.0b013e318185e196 · Cited by 42
Changing Team Member Perceptions by Implementing TeamSTEPPS in an Emergency Department
Obenrader, C., Broome, M. E., Yap, T. L., & Jamison, F. (2018) · Journal of Emergency Nursing · doi:10.1016/j.jen.2018.08.006 · Cited by 42
The Use of Multiple Qualitative Methods to Characterize Communication Events Between Physicians and Nurses
Manojlovich, M., Harrod, M., Holtz, B., Hofer, T. P., Kuhn, L. E., & Krein, S. L. (2014) · Health Communication · doi:10.1080/10410236.2013.835894 · Cited by 41
Trauma teams and time to early management during in situ trauma team training
Härgestam, M., Lindkvist, M., Jacobsson, M., Brulin, C., & Hultin, M. (2016) · BMJ Open · doi:10.1136/bmjopen-2015-009911 · Cited by 41
Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes
Brown, K. N., Leigh, J. P., Kamran, H., Bagshaw, S. M., Fowler, R. A., Dodek, P., Turgeon, A. F., Forster, A. J., Lamontagne, F., Soo, A., et al. (2018) · Critical Care · doi:10.1186/s13054-018-1941-0 · Cited by 42
Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department
Diaz, M. C. G., & Dawson, K. (2020) · American Journal of Medical Quality · doi:10.1177/1062860620912480 · Cited by 41
Addressing the Mandate for Hand-off Education
Lane-Fall, M. B., Brooks, A. K., Wilkins, S. A., Davis, J. J., & Riesenberg, L. A. (2013) · Anesthesiology · doi:10.1097/aln.0000000000000070 · Cited by 42
The relational underpinnings of quality internal auditing in medical clinics in Israel
Carmeli, A., & Zisu, M. (2009) · Social Science & Medicine · doi:10.1016/j.socscimed.2008.12.031 · Cited by 49
Impact of electronic prescribing in a hospital setting: A process-focused evaluation
Cunningham, T. R., Geller, E. S., & Clarke, S. W. (2007) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2007.10.008 · Cited by 40
Implementation of Unit-Based Interventions to Improve Teamwork and Patient Safety on a Medical Service
O’Leary, K. J., Creden, A. J., Slade, M. E., Landler, M. P., Kulkarni, N. S., Lee, J. J., Vozenilek, J. A., Pfeifer, P. B., Eller, S., Wayne, D. B., et al. (2014) · American Journal of Medical Quality · doi:10.1177/1062860614538093 · Cited by 40
Interprofessional and interdisciplinary simulation-based training leads to safe sedation procedures in the emergency department
Sauter, T. C., Hautz, W. E., Hostettler, S., Maeder, M. B., Martinolli, L., Lehmann, B., Exadaktylos, A. K., & Haider, D. G. (2016) · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine · doi:10.1186/s13049-016-0291-7 · Cited by 39
Attending Surgeons Differ From Other Team Members in Their Perceptions of Operating Room Communication
Grade, M. M., Tamboli, M., Merrell, S. B., Mueller, C. M., & Girod, S. C. (2018) · Journal of Surgical Research · doi:10.1016/j.jss.2018.09.030 · Cited by 39
Messaging to your doctors
Sun, S., Zhou, X., Denny, J. C., Rosenbloom, S. T., & Xu, H. (2013) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/2470654.2466230 · Cited by 39
Are You Listening...Are You Really Listening?
Denham, C. R., Dingman, J., Foley, M. E., Ford, D., Martins, B., O'Regan, P., & Salamendra, A. (2008) · Journal of Patient Safety · doi:10.1097/pts.0b013e318184db52 · Cited by 39
Classification of influencing factors of speaking-up behaviour in hospitals: a systematic review
van Dongen, D., Guldenmund, F. W., Grossmann, I., & Groeneweg, J. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-12138-x · Cited by 38
Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork
Sculli, G. L., Fore, A. M., Sine, D. M., Paull, D. E., Tschannen, D. J., Aebersold, M., Seagull, F. J., & Bagian, J. P. (2015) · Journal of Healthcare Risk Management · doi:10.1002/jhrm.21174 · Cited by 37
Promoters and barriers in hospital team communication. A focus group study
Rabøl, L. I., McPhail, M. A., Østergaard, D., Andersen, H. B., & Mogensen, T. (2012) · Journal of Communications In Healthcare · doi:10.1179/1753807612y.0000000009 · Cited by 37
Crisis Resource Management
Fanning, R. M., Goldhaber-Fiebert, S. N., Udani, A. D., & Gaba, D. M. (2013) · Springer eBooks · doi:10.1007/978-1-4614-5993-4_8 · Cited by 37
Applying fault tree analysis to the prevention of wrong-site surgery
Abecassis, Z. A., McElroy, L. M., Patel, R. M., Khorzad, R., Carroll, C., & Mehrotra, S. (2014) · Journal of Surgical Research · doi:10.1016/j.jss.2014.08.062 · Cited by 39
Effect of Program Type on the Training Experiences of 248 University, Community, and US Military-Based General Surgery Residencies
Sullivan, M. C., Sue, G. R., Bucholz, E. M., Yeo, H., Bell, R. H., Roman, S. A., & Sosa, J. A. (2011) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2011.09.021 · Cited by 36
Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies
Webster, J. S., King, H. B., Toomey, L. M., Salisbury, M. L., Powell, S. M., Craft, B., Baker, D. P., & Eduardo Salas, A. (2008) · Cited by 36
Improving physician communication through an automated, integrated sign-out system.
Frank, G., Lawless, S., & Steinberg, T. H. (2005) · PubMed · Cited by 36
Simulation for clinical research trials: A theoretical outline
Brindley, P. G., & Dunn, W. F. (2009) · Journal of Critical Care · doi:10.1016/j.jcrc.2009.01.009 · Cited by 35
Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action
Terezakis, S. A., Pronovost, P. J., Harris, K. M., DeWeese, T. L., & Ford, E. (2011) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(11)37037-7 · Cited by 35
Differences in Medical Error Risk among Nurses Working Two- and Three-shift Systems at Teaching Hospitals: A Six-month Prospective Study
Tanaka, K., Takahashi, M., Hiro, H., KAKINUMA, M., Tanaka, M., Kamata, N., & Miyaoka, H. (2010) · Industrial Health · doi:10.2486/indhealth.48.357 · Cited by 35
Use of Failure Mode and Effects Analysis for Proactive Identification of Communication and Handoff Failures from Organ Procurement to Transplantation
Steinberger, D., Douglas, S. V., & Kirschbaum, M. (2009) · Progress in Transplantation · doi:10.1177/152692480901900303 · Cited by 35
Alphanumeric Paging: A Potential Source of Problems in Patient Care and Communication
Espino, S. M., Cox, D., & Kaplan, B. J. (2011) · Journal of surgical education · doi:10.1016/j.jsurg.2011.07.006 · Cited by 35
“Speaking Up” for Patient Safety in the Pediatric Emergency Department
Eppich, W. (2015) · Clinical Pediatric Emergency Medicine · doi:10.1016/j.cpem.2015.04.010 · Cited by 37
Factors that drive team participation in surgical safety checks: a prospective study
Gillespie, B., Withers, T., Lavin, J., Gardiner, T. M., & Marshall, A. (2016) · Patient Safety in Surgery · doi:10.1186/s13037-015-0090-5 · Cited by 35
Medical Event Management for Future Deep Space Exploration Missions to Mars
Robertson, J. M., DIAS, R. D., Gupta, A., Marshburn, T. H., Lipsitz, S. R., Pozner, C. N., Doyle, T. E., Smink, D. S., Musson, D. M., & Yule, S. (2019) · Journal of Surgical Research · doi:10.1016/j.jss.2019.09.065 · Cited by 34
Reviewing High Reliability Team (HRT) Scholarship: A 21st Century Approach to Safety
Scott, A. L., Howe, W. T., & Bisel, R. S. (2022) · Small Group Research · doi:10.1177/10464964221116349 · Cited by 33
Rethinking the Discharge Summary
Lenert, L. A., Sakaguchi, F. H., & Weir, C. R. (2014) · Academic Medicine · doi:10.1097/acm.0000000000000145 · Cited by 33
Effectiveness of a course designed to teach handoffs to medical students
Chu, E. S., Reid, M., Burden, M. A., Mancini, D., Schulz, T., Keniston, A., Sarcone, E., & Albert, R. K. (2010) · Journal of Hospital Medicine · doi:10.1002/jhm.633 · Cited by 33
Handover training: does one size fit all? The merits of mass customisation
Kicken, W., van der Klink, M. R., Barach, P. R., & Boshuizen, H. P. A. (2012) · BMJ Quality & Safety · doi:10.1136/bmjqs-2012-001164 · Cited by 33
Information transfer in multidisciplinary operating room teams: a simulation-based observational study
Cumin, D., Skilton, C., & Weller, J. M. (2016) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-005130 · Cited by 33
Interprofessional Communication of Clinicians Using a Mobile Phone App: A Randomized Crossover Trial Using Simulated Patients
Patel, B., Johnston, M. J., Cookson, N., King, D., Arora, S., & Darzi, A. W. (2016) · Journal of Medical Internet Research · doi:10.2196/jmir.4854 · Cited by 33
Standardizing Handoff Communication
Nasarwanji, M. F., Badır, A., & Gürses, A. P. (2016) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000174 · Cited by 33
Communication between primary and secondary care: deficits and danger
Dinsdale, E. C., Hannigan, A., O’Connor, R., O’Doherty, J., Glynn, L. G., Casey, M., Hayes, P., Kelly, D., Cullen, W., & O’Regan, A. (2019) · Family Practice · doi:10.1093/fampra/cmz037 · Cited by 33
Using Conjoint Analysis to Model the Preferences of Different Patient Segments for Attributes of Patient-Centered Care
Cunningham, C. E., Deal, K., Rimas, H. L., Campbell, H., Russell, A., Henderson, J., Matheson, A., & Melnick, B. (2008) · Patient · doi:10.2165/1312067-200801040-00013 · Cited by 33
Communication Skills Training to Address Disruptive Physician Behavior
Saxton, R. (2012) · AORN Journal · doi:10.1016/j.aorn.2011.06.011 · Cited by 33
Imagining a continuing interprofessional education program (CIPE) within surgical training
Kitto, S. C., Gruen, R. L., & Smith, J. A. (2009) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.20034 · Cited by 33
Determinants of Adverse Events in Hospitals—The Potential Role of Patient Safety Culture
Kline, T. J. B., Willness, C. R., & Ghali, W. A. (2008) · Journal for Healthcare Quality · doi:10.1111/j.1945-1474.2008.tb01122.x · Cited by 33
Defining Speaking Up in the Healthcare System: a Systematic Review
Kane, J., Munn, L. T., Kane, S. F., & Srulovici, E. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-023-08322-0 · Cited by 32
Exploring the Impact of Toxic Attitudes and a Toxic Environment on the Veterinary Healthcare Team
Moore, I. C., Coe, J. B., Adams, C. L., Conlon, P. D., & Sargeant, J. M. (2015) · Frontiers in Veterinary Science · doi:10.3389/fvets.2015.00078 · Cited by 41
Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions
Woods, D. M., Holl, J. L., Holl, L., & Angst, M. D. (2010) · Cited by 32
Effectiveness of structured multidisciplinary rounding in acute care units on length of stay and satisfaction of patients and staff
Mercedes, A., Fairman, P., Hogan, L. J., Thomas, R., & Slyer, J. T. (2016) · The JBI Database of Systematic Reviews and Implementation Reports · doi:10.11124/jbisrir-2016-003014 · Cited by 32
Teams and Teamwork in Cancer Care Delivery: Shared Mental Models to Improve Planning for Discharge and Coordination of Follow-Up Care
Page, J. S., Lederman, L., Kelly, J., Barry, M. M., & James, T. A. (2016) · Journal of Oncology Practice · doi:10.1200/jop.2016.013888 · Cited by 32
Using Qualitative Methods to Explore Communication Practices in the Context of Patient Care Rounds on General Care Units
Manojlovich, M., Harrod, M., Hofer, T. P., Lafferty, M., McBratnie, M., & Krein, S. L. (2019) · Journal of General Internal Medicine · doi:10.1007/s11606-019-05580-9 · Cited by 32
Implementation of an Emergency Department Sign-Out Checklist Improves Transfer of Information at Shift Change
Dubosh, N. M., Carney, D., Fisher, J., & Tibbles, C. D. (2014) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2014.06.017 · Cited by 32
Using Simulation Education With Deliberate Practice to Teach Leadership and Resource Management Skills to Senior Resident Code Leaders
Burden, A. R., Pukenas, E., Deal, E. R., Coursin, D. B., Dodson, G. M., Staman, G. W., Gratz, I., & Torjman, M. C. (2014) · Journal of Graduate Medical Education · doi:10.4300/jgme-d-13-00271.1 · Cited by 32
Identifying intensive care unit discharge planning tools: protocol for a scoping review
Stelfox, H. T., Perrier, L., Straus, S. E., Ghali, W. A., Zygun, D., Boiteau, P. J. E., & Zuege, D. J. (2013) · BMJ Open · doi:10.1136/bmjopen-2013-002653 · Cited by 33
“Renters” or “Owners”? Residentsʼ Perceptions and Behaviors Regarding Error Reduction in Teaching Hospitals: A Literature Review
Padmore, J. S., Jaeger, J., Riesenberg, L. A., Karpovich, K. P., Rosenfeld, J. C., & Patow, C. A. (2009) · Academic Medicine · doi:10.1097/acm.0b013e3181bf51c1 · Cited by 31
Development and Psychometric Evaluation of the Impact of Health Information Technology (I-HIT) Scale
Dykes, P. C., Hurley, A. C., Cashen, M., Henry, S. B., & Duffy, M. E. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2367 · Cited by 31
The Effect of Health Information Technology on Health Care Provider Communication: A Mixed-Method Protocol
Manojlovich, M., Adler‐Milstein, J., Harrod, M., Sales, A. E., Hofer, T. P., Saint, S. K., & Krein, S. L. (2015) · JMIR Research Protocols · doi:10.2196/resprot.4463 · Cited by 33
Deception and Simulation Education
Calhoun, A. W., Pian-Smith, M. C. M., Truog, R. D., Gaba, D. M., & Meyer, E. C. (2015) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000086 · Cited by 31
High-Hanging Fruit: Improving Transitions in Health Care
Perry, S. J. (2010) · Cited by 31
Team Training in the Perioperative Arena: A Methodology for Implementation and Auditing Behavior
Rhee, A. J., Valentin-Salgado, Y., Eshak, D., Feldman, D., Kischak, P., Reich, D. L., LoPachin, V., & Brodman, M. L. (2016) · American Journal of Medical Quality · doi:10.1177/1062860616662703 · Cited by 31
Perceived Nurse—Physician Communication in Patient Care and Associated Factors in Public Hospitals of Jimma Zone, South West Ethiopia: Cross Sectional Study
Hailu, F. B., Kassahun, C. W., & Woldie, M. K. (2016) · PLoS ONE · doi:10.1371/journal.pone.0162264 · Cited by 31
Nurse practitioner malpractice data: Informing nursing education
Sweeney, C. F., LeMahieu, A., & Fryer, G. E. (2017) · Journal of Professional Nursing · doi:10.1016/j.profnurs.2017.01.002 · Cited by 35
Handing Over Patient Care: Is it Just the Old Broken Telephone Game?
Zendejas, B., Ali, S. M., Huebner, M., & Farley, D. R. (2011) · Journal of surgical education · doi:10.1016/j.jsurg.2011.05.011 · Cited by 31
Resident Sign-Out and Patient Hand-Offs: Opportunities for Improvement
Bump, G. M., Jovin, F., Destefano, L., Kirlin, A., Moul, A., Murray, K., Simak, D. M., & Elnicki, D. M. (2011) · Teaching and Learning in Medicine · doi:10.1080/10401334.2011.561190 · Cited by 30
The Role of Communication During Trauma Activations: Investigating the Need for Team and Leader Communication Training
Parker-Raley, J., Meenakshi, R., Dent, D. L., Willis, R. E., Lawson, K. A., & Duzinski, S. V. (2016) · Journal of surgical education · doi:10.1016/j.jsurg.2016.06.001 · Cited by 30
Handover practices of nurses transferring trauma patients from intensive care units to the ward: A multimethod observational study
Powell, M., Brown, D., Davis, C., Walsham, J., Calleja, P., Nielsen, S., & Mitchell, M. L. (2020) · Australian Critical Care · doi:10.1016/j.aucc.2020.03.004 · Cited by 30
Challenges in the Medical and Psychosocial Care of the Paediatric Refugee—A Systematic Review
Klas, J., Grzywacz, A., Kulszo, K., Grunwald, A., Kluz, N., Makaryczew, M., & Samardakiewicz, M. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191710656 · Cited by 30
Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine
Chang, A., Fernandez, H. M., Cayea, D., Chheda, S. G., Paniagua, M. A., Eckstrom, E., & Day, H. D. (2014) · Journal of General Internal Medicine · doi:10.1007/s11606-013-2752-2 · Cited by 30
Surgical Training and Education in Promoting Professionalism: a comparative assessment of virtue-based leadership development in otolaryngology-head and neck surgery residents
Schulz, K. A., Puscas, L., Tucci, D. L., Woodard, C. R., Witsell, D. L., Esclamado, R. M., & Lee, W. T. (2013) · Medical Education Online · doi:10.3402/meo.v18i0.22440 · Cited by 30
Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication
Bergman, A. A., Jaynes, H. A., Gonzalvo, J. D., Hudmon, K. S., Frankel, R. M., Kobylinski, A. L., & Zillich, A. J. (2015) · Health Communication · doi:10.1080/10410236.2014.940672 · Cited by 30
Hospital consultations and jurisdiction over patients: consequences for the medical profession
Oh, H. (2013) · Sociology of Health & Illness · doi:10.1111/1467-9566.12087 · Cited by 30
The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities
Schwartz, M. E., Welsh, D. E., Paull, D. E., Knowles, R., DeLeeuw, L. D., Hemphill, R. R., Essen, K., & Sculli, G. L. (2017) · Journal of Healthcare Risk Management · doi:10.1002/jhrm.21292 · Cited by 31

Authors: Sutcliffe, K. M., Lewton, E., & Rosenthal, M. M.
Affiliations: University of Michigan (US)
Corresponding author: Sutcliffe, Kathleen M.
Venue: Academic Medicine
Publisher: Oxford University Press (OUP)
Published: 2004-02
Volume: 79
Issue: 2
Pages: 186-194
ISSN: 1040-2446 (ISSN-L)
DOI: 10.1097/00001888-200402000-00019
OpenAlex: W2033026182
Cited by: 1,069
References: 14
Citations by year: 2026: 43 · 2025: 35 · 2024: 31 · 2023: 39 · 2022: 35 · 2021: 61 · 2020: 55 · 2019: 55 · 2018: 57 · 2017: 61 · 2016: 74 · 2015: 66 · 2014: 67 · 2013: 72 · 2012: 58
FWCI: 32.77
Type: journal article
Language: en
Open access: closed
Locations: Academic Medicine (publishedVersion)
PubMed (publishedVersion)
Deep Blue (University of Michigan) (submittedVersion)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
Keywords: communication breakdown, medical errors, patient safety, medical residents, clinical management, organizational factors, role ambiguity, health care organization, medical education
MeSH terms: Adult, Clinical Competence, Communication, Female, Hospitals, Teaching, Humans, Internship and Residency, Interprofessional Relations, Interviews as Topic, Male, Patient Care Management, Physician-Patient Relations, Physician's Role, Random Allocation, Sampling Studies, United States, Medical Errors

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review

Communication Failures: An Insidious Contributor to Medical Mishaps

Abstract

Overview

Integrity signals

Verification

Claims the paper makes

Claims other papers make about this one

Citations

Cites

Cited by

Related

Metadata

Record

About these checks