Risks to Collaboration

Risks related to communication, collaboration and care management.

March 10, 2021

Nurses in all settings face liability risk in their practice in many ways.

Risks related to communication, collaboration and care management are commonly associated with nurses in malpractice cases.  These risks and strategies to reduce them are discussed below.

Communication and collaboration of team members has been and continues to be a point of liability risk for nurses.  The nurse practice act in many states specifically assigns this coordination of care to the professional nurse. Nearly twenty years into the patient safety movement and efforts to improve communication have achieved only measured progress – many communication failures continue to occur.

Electronic health records and telehealth solutions have, in some cases, improved team access, awareness, and ability to be “on the same page”. In other cases, electronic records not being fully integrated around the patient becomes a barrier to complete and timely communication of key pieces of information. Telehealth solutions, when coupled with clear real-time communication based on protocols outlining accountabilities of all parties, support enhanced communication and timely care.

Transitions in care present an opportunity for communication to be incomplete or inaccurate.  Patient transfers and handoffs are frequently cited in malpractice cases as a contributing factor to harm. Handoffs that include the patient and the family and strategies like teach back are improving communication and addressing health literacy concerns.

Implementing a standardized communication tool and face-to-face bedside report when an ED nurse hands a patient off to the inpatient unit has proven effective. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program stresses standardized communication formats that are easy to remember and other strategies to improve teamwork. Kaiser-Permanente in Colorado developed SBAR (Situation-Background-Assessment-Recommendation) for team communication about patient condition, and SBAR is now used extensively. Many tools specific to improving care transitions and communication in ambulatory care have also been developed.

Lack of timely communication and follow-up to communication also commonly contribute to harm. The nurse has the duty to be certain that communication is being escalated. Follow up to communication must also occur.  Patient care orders, referrals, test results, and other communications must be initiated in a timely fashion, so appropriate care is not delayed. Communication received on behalf of a patient such as results of lab and diagnostic tests must be communicated without delay. This remains a challenge in all settings and delays appropriate care to the patient and, at times, results in worsening of the patient’s condition, harm, and even death.

Time and response to communications (including text messages) should be documented in the record.  Some electronic record systems include secure communication among the inter-professional team. Time stamps need to be accurate, and all communications should be saved in the permanent record.

Effective communication and collaboration support delegation. Nurses are required to supervise nursing care that has been delegated to others on the health team, evaluate the care, and make adjustments to the plan of care as needed. The nurse must assure that the training and experience of staff to perform what is delegated will accomplish the task effectively and protect the patient from potential harm.

Care management and coordination is another function ascribed to the registered nurse.  Inter-professional collaboration is being utilized more frequently to improve outcomes in all settings where nurses practice. A variety of daily or periodic team meetings or check-ins are occurring around the patient and including the family whenever possible.  These team meetings serve to coordinate care and provide early transition/discharge planning.  Coordination of care and discharge planning are areas commonly seen in nurse liability, so interventions to improve communication in these areas can reduce nurse liability.