The effectiveness of closed-loop communication training for healthcare providers on use, medical errors, and task performance: a systematic review

Abstract

Background: Patient harm from unsafe healthcare resulting in medical errors is an increasing global health challenge, ranking among the top causes of mortality on a global basis. These incidents often stem from clinical process failures, with a substantial proportion directly attributed to miscommunication and communication breakdowns. Numerous healthcare providers have admitted to having caused harm to patients due to communication shortfalls and uttered a desire to improve their communication skills. Closed-loop communication (CLC) is a long-standing skill taught in military settings to avoid miscommunication among team members, and places strong emphasis on verification to ensure that messages or orders are understood correctly. Nevertheless, CLC is still underutilized in medical practice.

Objective: The purpose of this systematic review was to investigate the effectiveness of CLC training for healthcare providers on increasing the use of CLC, reducing medical errors, and improving task performance.

Methods: Searches were performed in MEDLINE, EMBASE, CINAHL, CENTRAL, ERIC, and Google Scholar between the 10th and 14th of January 2024. To uncover further relevant studies, the reference lists of all included studies, related reviews, and relevant excluded studies, were screened. Participants eligible for inclusion were healthcare providers directly involved in patient care or assisted in providing it. CLC training in this review was understood as instructions that are designed to help individuals improve their ability to communicate effectively, with an emphasis on verification to ensure that messages or orders are understood correctly. The training had to be implemented either for the purpose of increasing the use of closed-loop communication between healthcare providers, or to achieve other desired outcomes related to patient safety through increased use of this particular communication strategy. Only randomized controlled trials were included, and risk of bias was assessed using the Cochrane (RoB 1.0) tool. The primary outcome was the frequency of closed-loop communication, and the secondary outcomes were medical errors and task performance. GRADE was used for rating the certainty of evidence. Due to considerable heterogeneity, a narrative approach was used to synthesize the results.

Results: All searches combined resulted in 1493 records, of which four studies with a total of 197 participants were included. Three studies from the U.S. and one study from Switzerland. One study had low or unclear risk of bias for all domains, while all the remaining studies had high risk of bias for at least one domain. All studies implemented a closed-loop communication training method comparing blindfolded simulations versus non-blindfolded simulations and measured the frequency of CLC. The results from the majority of the studies suggested more frequent use of CLC in the blindfolded group compared to the nonblindfolded group. However, the certainty of evidence for the primary outcome was rated as very low. Furthermore, one of the included studies reported a non-significant difference in the frequency of CLC, thus indicating some inconsistency in the findings. Two studies found that the blindfolded simulation training significantly reduced communication errors. There was a lack of statistically significant improvements in task performance measures, apart from some indication of a positive effect on non-clinical skills among team leaders.

Conclusion: Due to the several limitations of the evidence provided, the overall findings are not convincing enough to conclude that implementing a blindfolded simulation training as closed-loop communication training for healthcare providers will guarantee increased use of CLC, a reduction in the number medical errors, improved task performance, or produce the same results as shown in this systematic review, when replicated. That being said, the results suggested a potential positive effect on communicative behavior that should not be overlooked. To best inform about the effectiveness of closed-loop communication training, more research and larger studies are needed that also ideally include measure long-term effectiveness and retention.