Learning Objectives:

1. Identify how miscommunication contributes to medical errors.

2. Identify the role of the LNC in working on a catastrophic medical error case.

Errors are costly to patients, hospitals and insurance companies. Communication issues are the leading contributing factors resulting in patient injury. This session will focus on how communication factors lead to a variety of patient injuries. Specific guidance on the use of communication to avoid unexpected events will be provided. This session will utilize a case study where the breakdown in communication resulted in a sentinel event and cardiac arrest. Photos and videos will be shared detailing this unexpected and near fatal event as the participants follow the events and the emotional impact on the patient and the family. The role of the LNC in contributing to this case will be presented. The audience will learn how this woman's catastrophic event had an impact on every Joint Commission-accredited hospital.

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