Non-Clinical Tools

“To Err is Human...”[i]

Communicating in a Crisis

We all know that one of the major sources of error and conflict in our work is communication failure. Whether this break-down is with our colleagues, other medical teams, patients or families the potential for error is huge, and the resulting consequences of this mis-communication can be disastrous.

In recent years, there has been a greater focus on firstly recognising that communication is hugely complex and fraught with difficulty, and secondly on actively implementing strategies which can help us to reduce the risk of communication failure.

We would actively encourage each of you to read at least one of these excellent resources, and reflect upon your own practice.


Running a successful debrief is a huge skill in itself. In the midst of a crisis or busy emergency department there never seems to be ‘enough time’ or ‘the right time’ to do this. But as increasingly recognised, a good debrief can be an important part of the quality improvement process, as well as providing emotional support for staff. A timely debrief can give structure to your reflections on the case and provide clarity about sequence of events, including explaining the rationale for the decisions made, to all the staff involved with the case. Importantly, it can identify areas for improvement in a non-judgemental way – focusing on team performance rather than portioning individual blame, or highlight gaps in resources (human or equipment) which may be addressed for future patients.

One could spend months learning the skills required to run a successful debrief, but the following resources can give you a good introduction to some of the key component:

[i] To Err is Human. Institute of Medicine (US) Committee on Quality of Health Care in America; Editors: Linda T. Kohn, Janet M Corrigan, and Molla S. Donaldson. National Academies Press (US) 2000

© Agency for Clinical Innovation 2020

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