In To Err Is Human,11 the Institute of Medicine (IOM) reported that system failures are responsible for 44 000 to 98 000 deaths of patients each year. Communication issues have been cited as a top safety incident that causes harm in medical and surgical intensive care units (ICUs), with training and team factors as major contributors.22 Health care professionals are confronted with multiple communications (pagers, phone calls, wireless phones), interruptions and distractions, escalating noise, and limits to human performance in short-term memory from multitasking and stress/fatigue. Although it may seem that safe communication does not stand a chance against these odds, researchers in a recent ICU study33 found that nurses interrupted 42% of serious errors.

In their 2001 publication, Crossing the Quality Chasm,44 the IOM called for radical redesign of...

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