We found that patients with communication problems were 3 times more likely to experience a preventable adverse event than patients without such problems. These events were mainly drug related or caused by poor clinical management. Almost half of the events were associated with some level of disability or multiple hospital admissions, with one-third of the patients who experienced preventable adverse events requiring readmission to hospital. These results emphasize the importance of providing additional resources for these patients to improve patient safety.
Our findings build on those of earlier studies concerning patient communication and quality of health care.21–23
In a large North American survey, Iezzoni and colleagues22
found that participants with any major disability affecting communication were more likely than patients without such disabilities to be dissatisfied with physicians' understanding of their conditions and with the time spent discussing their problems and answering questions. Participants who were deaf or hard of hearing reported that they were very concerned with medication safety and other risks associated with inadequate communication, as well as communication problems during medical procedures.21
The results of a study by Steinberg and colleagues23
involving 54 deaf patients indicated that the minimal level of communication they have with health professionals would not be tolerated by hearing patients. In our study, half of the communication problems recorded were due to deafness, and most of the preventable adverse events were drug related or caused by poor clinical management (e.g., inappropriate treatment, delay in treatment, failure to monitor the patient's status). These types of errors relate to the concerns raised by deaf patients about inadequate communication.
Although the studies involving deaf patients22,23
did not specifically target hospital settings, the issues they raised are supported by findings of a study by Azoulay and colleagues18
about communication between physicians and families of patients in an intensive care unit. The authors found that factors such as foreign country of origin (p
= 0.007) and unfamiliarity with the official language (p
= 0.03) were associated with poor comprehension of diagnosis, prognosis and treatment: in 33% of cases, patient representatives were from foreign countries, and in 16% of cases they did not speak English or French. Although we did not specifically examine ethnic background as a potential communication barrier, in our study only 17% of the patients with a communication problem spoke 1 of the 2 official languages.
Our study is a retrospective chart review and, as such, has important limitations. First, chart reviews capture documented adverse events; however, they do not capture events that are rectified before any resulting injuries or complications occur. As a result, the rates of preventable adverse events are probably underestimated.34–36
To capture more potential adverse events, we did not require that the adverse event result in hospital readmission, permanent disability or death.15,34
Second, our chart review relied on the judgment of the physician and nurse reviewers, as well as the quality of the original charting. Our study achieved moderately high reliability, with kappa scores that were equivalent or better than those reported in studies using similar methodology.1,3–6
Communication disabilities are estimated to occur in 5%–10% of the general population and in up to 15% of hospital admissions.20,26
Therefore, our finding that 3% of our population had a documented communication barrier indicates that these disabilities may not have been systematically charted.
Third, our results are based on a limited number of preventable adverse events and a limited number of patients with communication problems. Despite the small numbers, we documented a 3-fold increase in risk that was both statistically and clinically significant. Furthermore, the number of preventable adverse events recorded in our study was similar to that found in previous studies of adverse events completed in Canada1,2
Our analysis adjusted for many of the other potential predictors of preventable adverse events. Therefore, our finding that the risk of a preventable adverse event is 3 times higher among patients with a communication problem than among patients without such problems remains robust and may be conservative.
To improve patient safety, a prospective controlled evaluation of the health care experience of patients with and without communication problems should be conducted. Clinicians and patients have proposed strategies for improving communication and optimizing the flow of information between the patient and the health care team.21,22,26
The impact of these proposed strategies on reducing the number of preventable adverse events and their impact on provision of care should be evaluated from the patient's perspective. Once the impact of interventions on preventable adverse events is assessed, patients with communication challenges can be identified at the time of admission to ensure they receive safe care.20,37
Our study was not designed to provide insight into how or why the presence of communication problems increases the occurrence of preventable adverse events. Therefore, it is important for future research to investigate interpersonal dynamics that may be responsible. This research will become critical as the number of adults with disabilities affecting communication increases as the elderly population increases.
@ See related article page 1573