Communication failures during clinical handovers lead to a poor patient outcome: Lessons from a case report

Abstract

In the emergency department, communication failures occur in clinical handover due to the urgent, changing and unpredictable nature of care provision. We present a case report of a female patient who was assaulted, and identify how various factors interacted to produce communication failures at multiple clinical handovers, leading to a poor patient outcome. Several handovers created many communication failures at diverse time points. The bedside medical handover produced misunderstandings during verbal exchange of information between emergency department consultants and junior doctors, and there was miscommunication involving plastic registrars. There was a failure in adequately informing th..