ArticleSAGE open medical case reports2015
Communication failures during clinical handovers lead to a poor patient outcome: Lessons from a case report.
Article in SAGE open medical case reports, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 8 papers.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
8 citing papers in PubMed.
- Preparing safe doctors through innovative methodologies: Importance and cost effectiveness of emphatic patient safety teaching to undergraduates.Pakistan journal of medical sciences · 2026Article
- Strategies to improve healthcare team communication structure and quality in resource-variable childhood cancer hospitals (TeamTalk): a study protocol.Implementation science communications · 2025Article
- Article
- Perceptions of Patients and Nurses about Bedside Nursing Handover: A Qualitative Systematic Review and Meta-Synthesis.Nursing research and practice · 2024Article
- Impact of the COVID-19 Pandemic on Neonatal Nursing Practicum and Extended Reality Simulation Training Needs: A Descriptive and Cross-Sectional Study.International journal of environmental research and public health · 2022Article
- Role-Play versus Standardised Patient Simulation for Teaching Interprofessional Communication in Care of the Elderly for Nursing Students.Healthcare (Basel, Switzerland) · 2021Article
- Developing an Evidence-Based Nursing Handover Standard for a Multi-Site Public Hospital in Switzerland: Protocol for a Web-Based, Modified Delphi Study.JMIR research protocols · 2020Article
- Remote Pediatric Critical Care Telephone Consultations: Quality and Outcomes.Journal of pediatric intensive care · 2019Article
Corrections and comments
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Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
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 the general practitioner and the patient relating to follow-up care after discharge. Deficiencies of communication occurred with conveying changes in an investigative report. Communication could be improved by dividing the conduct of handover in a quiet room and at the bedside, ensuring multiple sources of information are used and encouraging role-modelling behaviours for junior clinicians.
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Registered trials
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