The "Silent" Error Cascade: A Systematic Review on Communication Breakdowns at the Clinical-Laboratory-Navigation Interface and Impacts on Patient Care
Abstract
Background: Modern healthcare delivery relies on effective communication across various interprofessional teams—clinical, diagnostic, and administrative. Patient safety and outcomes are often compromised not by isolated errors, but by failures at the handoffs and interfaces among these groups, particularly involving nursing, medical laboratories, patient navigation, health informatics, and social services, creating a critical area for potential communication breakdowns.
Aim: This narrative review aims to synthesize and analyze the existing evidence on how miscommunication, information loss, and coordination failures at the clinical-laboratory-navigation interface contribute to diagnostic and treatment delays, missed social needs, and adverse patient outcomes.
Methods: A search was conducted across five electronic databases (PubMed, CINAHL, Scopus, Web of Science, and PsycINFO) for peer-reviewed studies published between January 2015 and June 2024. Data were extracted and synthesized using a narrative thematic approach.
Results: Analysis of the studies identified three main breakdown themes: (1) communication failures in result sharing among laboratory, nursing, and ordering providers; (2) gaps in care coordination and follow-up involving medical secretaries/navigators; and (3) fragmentation of social needs information across nursing and social service systems.
Conclusion: Communication failures between clinical, laboratory, and navigation services lead to significant patient safety risks and health equity issues. To address this, integrated interventions are needed, focusing on redesigning interprofessional workflows, optimizing electronic health records for teamwork, and formalizing patient navigation roles in communication. Future research should evaluate the effects of these interventions on clinical outcomes.
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Authors
Copyright (c) 2024 Abeer Ali Bitali, Ateyah Laheg Nami Alhadri, Sarah Homoud Alshal Alshallali, Ahlam Ayed Orayfij Alruwaili, Hakem Mubarak Dakhilallah Alsharari, Ohood Hassan Hadi Marwani, Abdulmohsen Zeyad Almotairy, Ibrahem Ali Mashny Shunaymir, Mohammed Hussein Mohammed Shaabi, Mihammed Hussien Dammas Matkooor, Aeih Mater Alosaimi, Rabaa Warad Alenze
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