Every 36 hours the NHS deals with over a million patients and each of these contacts probably generates discussion between staff about a patient’s care. Yet we know from serious incident investigations that communication failure is a common finding: we have come to expect direct or indirect reference to communication in most investigation reports.

We commissioned an interdisciplinary external working group to provide a better understanding of the issues surrounding both good and poor spoken communication of safety critical information. The group, made up of policy-makers, practising health professionals, NHS managers, academics and patient representatives, gathered evidence through workshops and focus groups, and by reviewing a wide range of literature, patient safety incident reports and patient feedback.

We have summarised the group’s findings and the six key areas it identified as presenting challenges to spoken communication. The full report includes examples of both good and poor practice.