Identifying Communication Precursors to Medical Error in an In-patient Clinical Environment: A Palliative Sedation Therapy Case Study

Abstract

Objectives: The objective of this thesis is to identify and understand communication and information exchange events and their influencing factors that are precursors to medical errors. Methods: Palliative Sedation Therapy is used as a case study to understand how communication and information sharing occur on an in-patient palliative care unit. Data sources were non-participant observation and interviews. Directed content analysis was used to analyze the data, with previously published conceptual models of communication acting as the guides for this analysis. Results/Discussion: Results identified several communication issues that have the potential to act as precursors to medical error at different points in the communication act. A model identifying the points where these precursors can impact communication was created. Conclusion: These results can be used to identify how improvements to communication and information exchange can increase the effectiveness of communication and reduce the likelihood of medical errors occurring.