Team Up for Patient Safety

Each year in March, Patient Safety Awareness Week highlights the shared responsibility clinicians have in creating safer systems of care. This year’s theme, “Team Up for Patient Safety”, reflects a central truth about modern healthcare: safe patient care depends on how effectively clinicians work together. While clinical expertise and sound decision-making remain essential, the way information is communicated across care teams often determines whether patients receive timely and appropriate treatment.

Healthcare today is rarely delivered by a single provider. Patients frequently interact with multiple clinicians across specialties, departments, and care settings. In this complex environment, communication serves as the connective tissue that allows teams to coordinate care, recognize changes in a patient’s condition, and act quickly when concerns arise. When communication is clear and timely, teams function more effectively. When it breaks down, important information can be missed, delayed, or misunderstood.

Candello malpractice data highlight how often communication failures among providers contribute to patient harm. According to the 2025 Candello Benchmarking Report, communication failures among providers were identified in 11,742 cases between 2014 and 2024. In many of these cases, the issue was not a lack of clinical knowledge but rather a failure to ensure that critical information was shared, interpreted, and acted upon.

The data reveal several common patterns in these events. Communication failures regarding a patient’s condition were the most frequently identified contributing factor, appearing in 63% of these cases. This may involve incomplete information shared during consultations, unclear communication of a patient’s status during transitions of care, or failure to notify another provider when a patient’s condition deteriorates, among others.

Another major contributing factor was the failure to appreciate and reconcile relevant signs, symptoms, and test results, which appeared in 39% of cases. This can occur when information is fragmented across multiple providers or when abnormal findings are not discussed or followed up appropriately. Without effective communication among team members, pieces of important clinical information may remain disconnected, preventing providers from seeing the full clinical picture.

Communication breakdowns are also known to affect the diagnostic process itself. Among these cases, failures or delays in ordering diagnostic tests were frequently identified as contributing factors. In team-based care environments, diagnostic decisions may depend on collaboration among multiple clinicians. Interventions such as hospital diagnostic excellence (DxEx) programs and ambulatory safety nets aim to streamline diagnostic workflows to improve diagnostic quality and safety.

Monitoring a patient’s physiological status was another contributing factor identified in communication-related cases. In many situations, deterioration in a patient’s condition was recognized but not clearly communicated or escalated to the appropriate team members. In busy clinical environments, the ability to recognize and communicate early warning signs is critical to preventing serious harm.

These findings reinforce the importance of strong teamwork in clinical care. Effective teams share information openly, clarify responsibilities, and confirm that important messages have been received and understood.

Several strategies can help support safer communication in team-based care. Structured handoffs, for example, can help ensure that critical information is consistently communicated during care transitions. Clear assignment of responsibility for follow-up tasks, such as reviewing test results or monitoring a patient’s status, can reduce the risk that important actions are overlooked. Closed-loop communication, in which information is confirmed and acknowledged by the receiving clinician, can help prevent misunderstandings.

Equally important is fostering an environment where team members experience psychological safety, i.e., feel comfortable raising questions or concerns. When clinicians feel supported in speaking up about changes in a patient’s condition or uncertainties in the care plan, teams are better positioned to recognize and respond to potential risks.

Patient safety is rarely the result of a single action or decision. More often, it reflects how well clinicians collaborate to share information, coordinate care, and support one another in complex clinical environments. As Patient Safety Awareness Week reminded us, strengthening teamwork and communication across care teams every day is one of the most powerful ways we can work together to improve outcomes and protect our patients.

Download the 2025 Benchmarking Report to learn more about communication’s role in medical professional liability cases.