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Closing the Communication Loop: Using Readback/Hearback to Support Patient Safety

      Since 1995 the Joint Commission on Accreditation of Healthcare Organizations has reviewed 2,455 sentinel events.

      Joint Commission on Accreditation of Healthcare Organizations: JCAHO Sentinel Event Statistics—January 29, 2004. http://www.jcaho.org/accredited+organizations/hospitals/sentinel+events/sentinel+event+statistics.htm (last accessed Apr. 21, 2004).

      Communication problems are consistently implicated as a leading factor in patient deaths and serious injuries (Figure 1, page 461). These data underscore the critical role of communication in care management and is consistent with findings from incident and accident analyses in other industries; front-line communication constitutes the bedrock of safety.
      • Weick K.E.
      The vulnerable system: An analysis of the Tenerife air disaster.
      • Bolman L.G.
      Aviation accidents and the theory of the situation.

      Taylor J., Patankar M.: The role of communication in the reduction of human error. Paper presented at the 14th Annual FAA/TC/CAA Maintenance Human Factors Symposium, Vancouver, British Columbia, Canada, Mar. 29, 2000.

      Review of Findings for Human Error Contribution to Risk in Operating Events. Report prepared by the Idaho National Engineering and Environmental Laboratory for the U.S. Nuclear Regulatory Commission. NUREG/CR-6753. Idaho Falls, NE. Aug. 2001.

      Figure 1.
      Figure 1Communication is the leading root cause of all sentinel events.
      Source: Joint Commission on Accreditation of Healthcare Organizations: JCAHO Sentinel Event Statistics-January 29, 2004. http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/root+causes+of+sentinel+event.htm (last accessed Apr. 21, 2004).
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      References

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      2. Taylor J., Patankar M.: The role of communication in the reduction of human error. Paper presented at the 14th Annual FAA/TC/CAA Maintenance Human Factors Symposium, Vancouver, British Columbia, Canada, Mar. 29, 2000.

      3. Review of Findings for Human Error Contribution to Risk in Operating Events. Report prepared by the Idaho National Engineering and Environmental Laboratory for the U.S. Nuclear Regulatory Commission. NUREG/CR-6753. Idaho Falls, NE. Aug. 2001.

      4. Joint Commission for Accreditation of Healthcare Organizations: Facts about the 2004 National Patient Safety Goals. http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/facts+about+the+04+npsg.htm (last accessed Apr. 21, 2004).

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        2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook.
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      5. Aeronautical Information Manual: Official Guide to Basic Flight Information and Air Traffic Control. Section 5 (5-5-2), Pilot/Controller Roles and Responsibilities, Air Traffic Clearance. Washington, DC: U.S. Department of Transportation, Federal Aviation Administration, Feb. 2004. http://www.faa.gov/ATpubs/AIM/index.htm (last accessed Apr. 21, 2004).

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