Characterization of Communication-Related Safety Events in a Pediatric Quaternary Care Hospital

Effective communication is essential for patient safety in complex pediatric health care environments. With the implementation of new interprofessional communication technologies such as secure messaging (SM), an updated understanding of communication breakdowns can inform targeted quality and safety interventions.

We aimed to identify and characterize communication-related safety events in inpatient pediatrics and subsequently determine the characteristics of interprofessional communication-related safety events specifically.

A retrospective observational study was conducted using safety events reported to the hospital's internal reporting system between March 2021 and March 2024 at a quaternary care pediatric hospital. Events were screened for communication involvement using keyword searches and expert reviewer classifications. Next, communication-related events were categorized using an existing communication failure mode categorization scheme. Disagreements among raters were resolved by consensus, and descriptive statistics were used to summarize the findings. A subanalysis of interprofessional communication failure types was also performed.

Of the 2184 confirmed communication-related events, Transfer/Handoff Communication Issues were the single most common type (22.0%, n=481). The most common failure mode identified was error of purpose/cognition (38.9%, n=850). Interprofessional communication events made up 58.3% of all communication-related events (n=1274). Errors of audience and errors of purpose/cognition were more commonly identified in interprofessional safety events.

A structured review process enabled the identification of communication events and failure modes, highlighting key areas for targeted safety interventions. Future efforts should focus on communicating shared mental models, reducing information omissions, and improving interprofessional communication models.