1) Effective communication between health professionals and patients is critical for patient safety. It allows clinicians to properly assess patient needs and risks, and involves patients as partners in their own care. 2) Barriers to communication, such as lack of health literacy or hierarchical traditions, can negatively impact patient safety by hindering understanding and efficient teamwork. 3) Strategies like using simple educational materials and confirming patient comprehension can help address these barriers and promote patient empowerment, safety, and better health outcomes through open dialogue and a partnership approach.

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COMMUNICATION DETERMINES PATIENT SAFETY
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Communication Determines Patient Safety
November 14, 2019 ‐ PSQH
By Cristina Vaz de Almeida
Partnerships with the patient start with cooperation and commitment, where the health
professional must be close to the patient to act as a true “observer.” Observation allows the
clinician to assess the patient’s needs and “essence,” enabling the relationship to grow and
promoting favorable health outcomes.
Communicating effectively allows us to clearly mark risks and measure patient safety limits.
Partnerships with the patient start with cooperation and commitment, where the health
professional must be close to the patient to act as a true “observer.” Observation allows the
clinician to assess the patient’s needs and “essence” (Egener & Cole-Kelly, 2004), enabling the
relationship to grow and promoting favorable health outcomes.
Ricciardi & Shofer (2019) highlight the need for patients to be involved in their care by asking
health professionals about their diagnosis and treatment through an open dialogue. When
patients are involved as partners, they can detect adverse events and ensure safe care as well
as promote a safety culture.
One of the public health doctors who participated in an in-depth interview for this paper says,
“It is undoubtedly very important to develop communication skills in all their transversality,
both verbal and nonverbal communication techniques, and I stress again the delivery of
reminders/recipes/visual schemes that support the message conveyed.” To this doctor, verbal
and nonverbal communication are critical to establishing effective trust and information
exchange.
There are also useful tools that promote interpersonal relationships. The Agency for
Healthcare Research and Quality (2019), for example, has “My Questions for This Visit,” a
simple and effective card that gives patients a list of questions to ask during the medical
meeting, such as:
1) What are my medications?

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2) What tests and analyses do I need?
3) What surgery should I undergo?
The AHRQ Health Literacy Universal Precautions Toolkit, Second Edition, enables an
intervention in primary care practices by seeking to reduce the complexity of healthcare;
increase patient understanding of health information; and produce improvements in patient
support at all levels of health literacy (Brega et al., 2015).
Several surveys show that up to 75% of hospital readmissions could be prevented by
interventions aimed at greater patient and family involvement and cooperation, such as health
education; pre-discharge assessment and coordinated home care; and family and patient-
centered care (Mitchell, Heinrich, Moritz, & Hinshaw, 1997).
The subject of patient safety arose from the healthcare quality movement, which has been
defined by the Institute of Medicine as “prevention of harm to patients” (Aspden, Corrigan,
Wolcott, & Erickson, 2004). Emphasis is placed on a healthcare delivery system that avoids
mistakes and learns from those that occur, based on a safety culture involving healthcare
professionals, organizations, and patients.
The AHRQ Patient Safety Network later expanded the definition of harm prevention to include
“the freedom from accidental or preventable injuries caused by medical care” (AHRQ PSNet,
n.d.). Although the definition is not yet complete (Mitchell, 2008), patient safety practices have
been defined as “those that reduce the risk of adverse events related to medical care exposure
in a variety of diagnoses or conditions.”
Mitchell (2008) states that the origins of the patient safety problem are classified in terms of
type (error), communication (e.g., failures between professionals or between patient and
professional, and between professionals and non-medical staff), patient management (e.g.,
inadequate delegation, failure to follow up, incorrect referral, or misuse of resources), and
clinical performance (before, during, and after the intervention).
Strategies to prevent patient safety errors and improve healthcare processes (Hughes, 2008)
include the use of simulators, bar codes, and computerized entry via clinical applications, as
well as team resource management. Communication is an effective way to improve patient
safety, especially if it’s assertive, clear, and positive (Belim & Vaz de Almeida, 2017).
Discussion and results
These reflections resulted from a qualitative study with Portuguese nurses (n = 30) who
participated in five focus groups from August to October 2019 and from five in-depth
interviews with health literacy specialists. The focus groups and interviews were assessed
separately and then combined and compared. Thematic analysis is a very useful approach for
producing quality analyses (WHO, 2019).
As mentioned in the focus groups, with qualitative content analysis, patient support has to be
given in stages, and the health professional must always confirm that the patient has

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acknowledged and understood the information. In an in-depth interview, an organ transplant
coordinator (a medical doctor) at a large reference hospital in the greater Lisbon area of
Portugal said that sometimes, doctors think certain words or phrases are understandable but
the family does not actually comprehend them. These include “the patient is in a stable
situation,” where the family thinks the patient is about to be in good health, or “the patient
has kidney failure,” where the family simply does not understand what “kidney failure” means.
Any care transition, whether to a different unit in the hospital, to a separate hospital, or to the
patient’s home, increases risk. Communication between the team and the patient or family
should be a factor to consider in risk consequences. In addition to written information, the
health professionals in the focus groups said that communication must be accurately and
intelligibly conveyed to the patient and family, because certain communications are very
difficult to understand.
Focus group participants, especially those in physical medicine and rehabilitation, stressed the
importance of talking clearly, assertively, and respectfully to patients and families. The
components of the healthcare professional’s verbal and nonverbal language may be innate,
but according to focus group participants, professionals “need to be learned and trained to
produce even more effective patient outcomes, especially given the critical need for their
understanding and safety in action.” Harmony and reciprocity between the patient and
professional allows communication that flows easily and is mutually understandable.
Focus groups also noted the need for patient training to be an active partnership.
Empowerment as a way to promote commitment is an established concept for healthcare. In
this clinical and communicative process, an overview of the patient is helpful and promotes
better results.
The health professional should be an “observer” reporting on the rehabilitation health
professionals participating in the focus group. In this domain, the professional should get used
to looking at patients in their physiological, psychological, social, and cultural dimensions.
Cultural beliefs can also be a barrier to real commitment and involvement from both patients
and practitioners. One such barrier is the hierarchical tradition, based on clinicians’ training as
figures of power and authority. The focus groups confirmed that this hegemony of physicians
still exists in some organizations, even between doctors and nurses, contributing to poor
communication as a reflection of patient safety “when teams do not understand each other.”
Ricciardi & Shofer (2019) stress that these more hegemonic styles can lead to a dictatorial style
of management, which in turn can lead to inefficient and insecure teamwork.
We must also mention the spread of universal precautions in health literacy. These precautions
aim to simplify communication and confirm patient understanding, thereby minimizing
miscommunication; easing navigation in the consultation environment and the health system;
and supporting patients’ efforts to improve their health.
With these points on attitude and safety behaviors in mind, we can reflect on the ongoing need
for open dialogue with the patient through assertive behavior and communication, clear

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language, and positive action where partnership, reciprocity, and a holistic vision of a true
health professional “observer” are always present to improve health outcomes.
Cristina Vaz de Almeida is director of Post Graduate Course on Health Literacy at ISPA in
Portugal; she is also a PhD student in communication science and health literacy at ISCSP.
Figure 1: Communication for Better Health Literacy and Health Outcomes
References
AHRQ PSNet. (2019, June). Tips & tools: Questions are the answer. Retrieved
from https://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/tips-
and-tools/index.html
AHRQ PSNet. (n.d.). Patient safety. Retrieved from https://psnet.ahrq.gov/glossary/p
Aspden, P., Corrigan, J., Wolcott, J., & Erickson, S. M. (Eds.). (2004). Patient safety: Achieving a
new standard for care. Washington, DC: National Academies Press.
Belim, C., & Vaz de Almeida, C. (2017). Healthy thanks to communication: A model of
communication competences to optimize health literacy: Assertiveness, clear language, and

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positivity. In V. E. Papalois & M. Theodospoulous (Eds.), Optimizing health literacy for improved
clinical practices (pp. 124–152). Hershey, PA: IGI Global.
Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., … West, D. R.
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Egener, B., & Cole-Kelly, K. (2004). Satisfying the patient, but failing the test. Academic
Medicine, 79(6), 508–510.
Hughes, R. G. (Ed.) (2008). Patient safety and quality: An evidence-based handbook for
nurses. Rockville, MD: Agency for Healthcare Research and Quality.
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Ricciardi, R., & Shofer, M. (2019). Nurses and patients: Natural partners to advance patient
safety. Journal of Nursing Care Quality, 34(1), 1–
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