Patient Safety
Aiya Almogaber, PharmD
A systematic review published in the Annals of Internal Medicine casts a spotlight on the critical role communication plays in patient safety incidents across health care settings. Drawing on recent data from thousands of patients and practitioners worldwide, the review, published April 15, 2025, underscores how lapses in communication—whether between health care professionals or with patients—remain a leading contributor to preventable harm.
The review’s findings reveal a striking and persistent link between poor communication and patient safety incidents across diverse health care environments. Among the 46 studies analyzed, poor communication was identified as the sole cause of 13.2% of safety incidents. When communication failures were considered as one of multiple contributing factors, the proportion rose to a median 24.0% of incidents. These findings highlight communication breakdowns as a leading, and often preventable, source of harm to patients.
The consequences of these failures were wide-ranging as well, according to the findings.
Patient safety incidents linked to communication errors included medication errors, delays in diagnosis and treatment, near misses, and life-threatening complications.
The Joint Commission has reported that more than 60% of hospital-based adverse events in the United States involved communication problems, an issue mirrored globally. In the United Kingdom, for instance, over 1,700 lives are lost each year due to medication errors, many of which are tied to miscommunication.
New scope and rigor
Unlike earlier reviews, which typically focus on specific outcomes or professions, this one aimed for broad scope. The research team systematically analyzed studies spanning practitioner-to-practitioner, practitioner-to-patient, and interdisciplinary communication in a variety of health care environments. These included hospitals, family medicine clinics, and outpatient settings across Europe, Asia, North America, and beyond.
The authors were motivated by the alarming scale of preventable harm in health care, and the limitations of past reviews, which often siloed communication failures by setting or discipline. Their goal was to evaluate the impact of communication breakdowns across all types of safety incidents.
According to the findings, communication between health care professionals contributed to safety incidents in 30 of the 46 studies. Examples included failures during shift handovers, misinterpreted verbal orders, inadequate documentation, and missing care plans. The reported impact of poor communication ranged widely, from 3% to over 80% in some settings.
“Effective communication is not just a soft skill—it is critical to patient safety,” the authors said.
They urge health care providers to prioritize regular, evidence-based communication training—from undergraduate education through continuing professional development.
Challenges and research needs
The authors noted that while the findings largely aligned with expectations, the magnitude of the problem exceeded initial assumptions. They explained that the variability in study quality and reporting standards limited their ability to perform meta-analyses, and they have called for more standardized, rigorous research in this area.
They emphasized that defining concepts such as “effective communication” and “patient safety incidents” from the outset was essential for ensuring transparency and rigor. Clear definitions, they said, were foundational to the integrity of the review and should be a priority for researchers entering this space.
The research team also underscored the need to move beyond simply identifying associations. Future research should investigate the mechanisms by which communication failures lead to harm, explore causal pathways, and pinpoint ways to develop targeted interventions with patient safety outcomes as primary endpoints, they noted. ■