■ Physician-team:

Leveraging the power of collaboration to foster safe care

Team miscommunication

Published: August 2021

Type of activity: Video

Activity summary

The short video "Team miscommunication" portrays poor communication within an inter-professional team and the subsequent death of their patient. The facilitation questions and suggestions to faculty focus on helping learners to identify what went wrong, and how to improve communication within an inter-professional team.


Setting: Physician speaks to a family member in tears

Betty Edwards: I can't believe this could happen. He was doing so well. He was making such good progress after his stroke. I don't understand how he could suddenly die from a blood clot.

Voice over: Each of the following team members possess some information about the patient's condition that might have led to a different outcome.

Physiotherapist: I noticed for the last 2 physio sessions that he seemed to be having more trouble walking. His right leg seemed to be hurting.

Pharmacist: I noticed Mr. Edwards wasn't taking any prophylactic anticoagulants to prevent DVT. I was going to mention it to the team.

Nurse: Over the weekend I called the on call physician. Mr. Edwards had been getting more anxious and seemed to be hyperventilating and was quite diaphoretic. The on call resident gave him a benzodiazepine to help him sleep. I think he was still anxious though as his pulse was still 130. I didn't want to disturb the resident again about it in the middle of the night.

Resident 1: Mr. Edwards is anxious and doesn't really like hospitals. The nurse called me about him, again, so I prescribed him a sedative. Guess it worked because I didn't hear back.

Setting: Handover at nursing station with 2 residents, 2 nurses, physiotherapist and pharmacist

Resident 2: Ok, you've got 12 inpatients. Let's see, in room 1, Mr. Edwards, had a stroke on June 3rd. He's been here for 2 weeks. He's waiting for a rehab bed which may be available at the end of the week.

Nurse: Ok, bed 2?

Concluding facilitation question: How might this clinical outcome have been avoided?

Facilitation questions

  1. How might this clinical outcome have been avoided?
  2. What are some tools and techniques the team could have employed to better communicate with each other?
  3. Identify any evidence of individual or team situational awareness portrayed in the video.

Suggestions to faculty

Other communication topics that may be explored using this video include “Physician-team: Psychological safety”, CMPA Good practices and “Physician-team: Transitions in care”, CMPA Good practices. For example, ask learners to identify the barriers to effective handovers portrayed in the video. As a follow-up question, ask them to explain when and how speaking up may have prevented the patient's death.

CanMEDS: Collaborator, Communicator, Professional

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.