Patterns for Communications Breakdowns Between Health Care Providers

• to notify someone of a serious problem or event?

• to comprehend the significance of a finding?

• to clearly establish responsibility?

• to follow protocol?

• because of a difference in status between the healthcare providers?

• during a transfer in care (hand-off)?

• following a change in the patient's physical location?

• associated with an uncertainty in role?

• during a period of high workload or competing tasks?

• because it was assummed that a message had gotten through?