Page 62 - JSOM Spring 2025

Miscommunication and Risk in the Military Prehospital Environment

A Case Series and Review

SSgt Griffin D. Elzey, MD, NRP *; CAPT Michael J. Lauria, MD, NRP, FP-C ;
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Lt. Col Stephen C. Rush, MD 3

ABSTRACT
Good communication on a medical team is essential to opti- recent studies found miscommunication to be primarily verbal,
mize patient care and reduce human error risk. While this is which drives current or remaining mitigation strategies largely
well documented for civilian medicine, there is a paucity of toward methods for reducing verbal miscommunication. 7
research in the military prehospital environment (MPE). We
analyzed four cases of miscommunication in the MPE: during Miscommunication, in and of itself, is complex because it can
a casualty handoff, within a team during a tactical medical occur in various forms. These include but are not limited to
operation, between a medic and a doctor during a mass ca- patient misidentification, medication misadministration (e.g.,
sualty event, and in a helicopter while caring for a casualty. wrong medication, wrong dose, or wrong route of adminis-
One mission had an adverse outcome, another had a rescue tration), misunderstanding of medical procedures, and mis-
team disruption during operations, and two cases had errors communication during the handoff between providers during
without adverse outcomes. In each case, closed-loop commu- a patient encounter. In fact, provider handoff was the most
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nication with readbacks may have reduced or prevented actual common source of miscommunication, which indicates it is an
or potential patient harm and optimized timely patient care. optimal area of focus for risk mitigation. The areas of focus
All branches of military prehospital medicine should employ needed to improve this critical phase of patient care are an
efforts and techniques that ensure standard, reliable commu- increased level of detail, allowing for sufficient time to accom-
nications during medical operations to prevent adverse patient plish the handoff, and improvements to the documentation
outcomes. process. 3,6

Keywords: miscommunication; communication; military; In addition to the volume of studies highlighting the var-
prehospital; handoff; mass casualty ious types of miscommunication, numerous resources for
evidence-based solutions exist. Many of these solutions de-
scribe alleviating the precipitating factors, such as reducing
interruptions during drug retrieval and administration or
Introduction
allocating more time for handoffs . Other recommendations
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Miscommunication is a leading contributing or causal compo- include standardizing processes like “time-outs,’’ where all
nent of human error in patient care. Efforts have been made providers involved in an upcoming patient procedure take a
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to improve communication in the hospital setting to reduce few minutes to focus only on the salient details of the medical
this type of human error. Although miscommunication intervention prior to it commencing. 5,6,9
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would be expected to apply to the MPE, it has not yet been
studied or described in the medical literature for this unique Some interventions for reducing miscommunication that have
environment. proven successful in the civilian medical context would be ex-
pected to apply to MPE. During combat, miscommunication
Numerous studies highlight the errors induced by miscommu- might not only result in an adverse outcome for the patient but
nication in both the clinical and hospital settings. 1,3,7–9 At least could also adversely impact the mission. Effective communica-
2.5% of all patients experience preventable harm because of tion interventions are essential to maintaining overall safety
miscommunication in the civilian healthcare setting. Gawande and military readiness.
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et al. found that nearly half of all surgical errors were attrib-
utable to miscommunication in a controlled environment such This retrospective case series review includes four cases of
as the operating room. A 2019 systematic review found that miscommunication in the MPE contributing to medical error,
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5% of patients experience preventable harm secondary to er- adverse operational outcomes, or both. Similarities with civil-
rors in the hospital. The most common causes of preventable ian medical miscommunication are noted, though the unique
harm were errors in drug administration and therapeutic treat- circumstances within the MPE make patient care more chal-
ments, followed by surgical error and infection. Evidence sug- lenging and increase the likelihood of miscommunication. We
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gests these types of medical errors can be attributed mainly to explore solutions from the civilian literature applicable to
miscommunication, further emphasizing the need for medical improving combat medical care and consider new tactics to
communities to acknowledge and address this risk. Of note, enhance military prehospital care.
*Correspondence to griffin.elzey@gmail.com

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