1) Miscommunications are implicated in nearly all adverse events described in case studies reviewed from a healthcare complaints commission, rather than systems failures or preventable medical errors. 2) Recipients of healthcare describe a wider range of harms from services, including mental, emotional and relational impacts, rather than just physical injuries as defined in previous adverse event studies. 3) There is a need for health institutions to critically examine the harms caused by miscommunications and consider how to address this leading cause of adverse events reported by patients.