Safety of care

Improving patient safety and reducing risks

Coordinating critical care: Communication challenges for providers and patients

Originally published June 2016
P1602-5-E

Effective coordination of care is central to ensuring patient safety in the hospital. But, healthcare transitions or handovers are particularly challenging for patients requiring critical care. Factors such as frequent interruptions,1 the complexity of patients’ conditions and the required constant monitoring,2 and the need for full and frequent involvement of families or substitute decision-makers3 place added demands on the transfer of care in hospital.

The CMPA analyzed its medical-legal cases that involved patients in the intensive care unit (ICU) to identify issues with the coordination of care. Particular emphasis was placed on communication breakdowns that occur between departments or healthcare facilities. This analysis of 47 cases, closed between 2010 and 2014, found that these breakdowns occurred not just between healthcare professionals, but also between the care team and patients and their families.

A recurring theme was identified in the cases reviewed. Important clinical information was not being communicated during handovers, as evident in more than a quarter of cases. The missed information was most commonly about the patient’s acuity level; care plans, including tests performed and requiring follow-up; and medications, either received before transfer, or to be discontinued or resumed after transfer. These knowledge gaps often led to the receiving care team giving inappropriate care. Information was often missing because of non-structured handovers that lacked direct or face-to-face communication or the involvement of all members of the care team, as well as inadequate documentation.

More than a third of cases involved poor communication with families. Information not adequately shared or explained to families mainly related to the care plan including end-of-life decisions, consent discussions, the roles and responsibilities of the physicians involved in the patient’s care, and plans to transfer the patient. In their complaints families sometimes reported receiving mixed messages from different care providers.

System issues also played a role. In these cases, peer expert criticism focused on inadequate systems for tracking test results, lack of structured communication protocols for handovers, no reconciliation of medications, delays in the receipt of test results, and issues with access to critical information within an electronic health records system.

Issues within the ICU

Patient monitoring was the most frequently identified issue with coordination of care within the ICU. Specifically, healthcare professionals did not fully appreciate and communicate the significance of a patient’s deteriorating condition. Occasionally, cases involved members of the care team having difficulty reaching the required physician in an emergency. Other issues within the ICU were the same as with intra-hospital transfers. The most responsible physician for the patient’s care was not clearly identified, communication with patients or their families was inadequate, and (intra-shift) handovers were poor.

Information breakdown

Case example

Late in the afternoon, a stable, elderly male with heart disease is transferred to the ICU for monitoring of post-operative bleeding after endovascular aortic aneurysm repair. The resident on call accepts the handover from a nurse.

The patient is assessed several times that evening. During that time his hemoglobin drops to 81 g/L. The resident orders one unit of packed red cells. Two nurses administer the transfusion in the middle of the night while the patient is sleeping.

The next morning, while reviewing the patient’s record, the resident discovers a “Refusal of consent to blood and blood products” form indicating that the patient objects to these interventions on religious grounds. The resident advises the attending of this error, and a disclosure meeting is held later that day between the patient, his family, and several members of the healthcare team. The patient later files a legal action.

The CMPA, on behalf of the resident, and the hospital, on behalf of the nurses, pay a settlement to the patient. Hospital handover protocols requiring physician-to-physician transfer of information were not followed, appropriate precautions were not taken to identify a patient who had refused blood products, and nurses did not check with the patient before administering the transfusion. There was no expert support for the care provided by the resident as he did not read all relevant parts of the medical record before ordering a blood product.

Optimize handover

Suggested approaches based on experts’ opinions in the cases reviewed:

  • Consider using a structured communication tool for sharing information during handovers.
  • Take a structured approach to reconciling key information from the patient profile (e.g. medications, allergies, and patient wishes including advance directives and special exemptions) at every transition of care. Ensure that important information is flagged for all members of the healthcare team. For example, communicate via signage, patient bracelets, verbally, or in writing.
  • Verify the availability of advance directives and ensure that this information is communicated at handovers so that patients’ wishes are respected in the event they are unable to communicate.

Lack of care coordination

Case example

A young person with multiple injuries from a motor vehicle collision is being cared for in the ICU. The orthopaedic surgeon (surgeon A) on call that evening orders a series of X-rays to evaluate the extent of the patient’s injuries, which include multiple fractures to the spine and ribs.

The X-rays are read the following day by the next orthopaedic surgeon on call (surgeon B). Surgeon B decides to perform a reduction under sedation to correct a dislocated elbow, after obtaining consent. Post-reduction, surgeon B notes some instability in the joint. He orders a follow-up X-ray and, at the end of his shift, informs the nursing staff that the orthopaedic surgeon coming on call the next day (surgeon A) will be assuming the patient’s care and asks them to inform the surgeon of the need to review the X-ray.

Three weeks later, surgeon A, who cared for the patient post-reduction, evaluates the patient again to assess the mobility in the arm. He notes instability and orders an X-ray of the elbow. When the X-ray, which shows persistent dislocation, is read, the initial post-reduction X-ray, which shows the same result, is discovered.

The patient files a legal action alleging that the delay to diagnose persistent dislocation contributed to ongoing pain and the need for additional surgery. A peer expert criticizes the handover, stating that surgeon B should have communicated directly with the next physician, surgeon A, about the post-reduction X-ray. Furthermore, the expert notes, both surgeons met several times over the month and therefore had opportunity to discuss this patient’s case. The longer than acceptable wait for imaging results was also criticized — this caused the report to be missed over a shift change. The CMPA, on behalf of both surgeons, and the hospital, on behalf of the nurses, pays a settlement to the patient for the miscommunication and for the inadequate imaging protocols.

Establish the plan

Suggested approaches based on experts’ opinions in the cases reviewed:

  • Verbally communicate information relevant to the patient’s care directly to the most responsible physician at handover.
  • Ensure a reliable system is in place to facilitate the timely receipt, effective review, and appropriate follow-up of imaging reports.
  • Consider scheduling periodic briefings or “huddles”4 to review patient needs and care plans with all staff in the department involved in the care of the patient.

Poor communication with the patient or family

Case example

A regulatory authority (College) complaint is filed by the family of a middle-aged woman who died of a pulmonary embolism a day after being discharged from the hospital following complications from surgery. They allege that poor communication within the ICU led to her death.

The patient had experienced an anastomotic leak and abscess following a hemicolectomy to remove a suspicious lesion. These complications required she undergo additional surgery and admission to the ICU for monitoring. The family felt the patient was discharged too soon from the ICU and that her condition was not being taken seriously — the ICU physician decided to discharge the patient much sooner than the family expected based on what they had been told on the patient’s admission to the ICU. They also claim that at several points they were unaware of which physician was responsible for the patient’s care.

The College committee investigates the family’s complaints and determines that care was appropriate. Transfers of care were well documented, the decision to discharge from ICU was appropriate given the patient’s clinical picture at the time, and protocols for VTE prophylaxis were followed. The committee acknowledged, however, that communication with the family could have been improved as it was clear that the family members did not understand how and why care decisions were being made.

Foster open communication

Suggested approaches based on experts’ opinions in the cases reviewed:

  • When multiple physicians are involved, confirm that the reason for the transfer of care is clear to the patient, family, or substitute decision-maker.
  • Tailor your communication style to the individual’s needs.
  • Document the information shared with the patient, family, or substitute decision-maker in the medical record, including the rationale supporting decisions about tests, treatments, discharge, and plans for follow-up.

The bottom line

This analysis highlights the importance of effective communication in the critical care context — not just between professionals, but also with patients, their families, or their substitute decision-makers. Reliable communication protocols, developed within a quality improvement framework, can help prevent the most common problems associated with poorly coordinated care. 


  1. Alvarez G, Coiera E. Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform. 2005 Oct;74(10):791-6.
  2. Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med. 2011 Sep;124(9):860-7.
  3. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008 Oct;134(4):835-43.
  4. Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013 Jan;131(1):e298-308.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.