COMMUNICATION FAILURE MAPPING TOOL
A structured framework for identifying, mapping, and analyzing communication breakdowns across all healthcare settings.
Communication failures are among the most common—and preventable—contributors to patient harm. This tool helps attorneys identify missed notifications, delayed escalation, incomplete handoffs, and breakdowns in interdisciplinary communication.
Use this tool during case screening, timeline reconstruction, breach analysis, and deposition preparation.
COMMUNICATION PATHWAYS OVERVIEW
✔ Identify All Communication Channels
• Nurse → Provider
• Nurse → Nurse
• Nurse → Aide/CNA
• Nurse → Therapist
• Staff → Family/Caregiver
• Facility → Hospital (transfers)
• Facility → Pharmacy
• Facility → EMS
• Corporate → Facility (policy, staffing, QA
✔ Map Expected vs. Actual Pathways
• What communication should have occurred
• What communication actually occurred
• Missing or delayed steps
PROVIDER NOTIFICATION MAPPING
✔ Track Key Notifications
• Change in condition
• Abnormal vitals
• Abnormal labs
• New symptoms
• Medication issues
• Falls or injuries
• Wound deterioration
✔ Identify Failures
• No provider notification
• Delayed notification
• Incomplete information provided
• No follow‑up after notification
• Provider unaware of deterioration
INTERDISCIPLINARY COMMUNICATION
✔ Map Communication Between Staff
• Nurse ↔ Therapist
• Nurse ↔ Aide/CNA
• Nurse ↔ Charge Nurse
• Nurse ↔ DON
• Nurse ↔ Pharmacy
• Nurse ↔ Social Worker
✔ Identify Failures
• No communication of safety risks
• No communication of functional decline
• No communication of wound changes
• No communication of medication issues
• No communication of abnormal labs
FAMILY & CAREGIVER COMMUNICATION
✔ Track Required Communication
• Change in condition
• New symptoms
• Falls or injuries
• Transfers
• Medication changes
• Care plan updates
✔ Identify Failures
• Family not notified
• Delayed notification
• Incomplete or inaccurate information
• No documentation of communication
TRANSFER & HANDOFF COMMUNICATION
✔ Required Handoff Elements
• Reason for transfer
• Vitals
• Labs
• Medications
• Recent changes in condition
• Interventions performed
• Pending orders
• Safety risks
✔ Identify Failures
• Missing handoff
• Incomplete handoff
• Contradictory information
• No documentation of communication with the receiving facility
ESCALATION FAILURE MAPPING
✔ Track Escalation Steps
• Recognition of deterioration
• Notification of charge nurse
• Notification of provider
• Interventions ordered
• Reassessment
• Transfer decision
• EMS activation
✔ Identify Failures
• No escalation despite red‑flag symptoms
• Delayed escalation
• Escalation to wrong person
• No reassessment after escalation
• No follow‑up after new orders
DOCUMENTATION OF COMMUNICATION
✔ Review for Documentation
• Time of communication
• Who was notified
• What information was provided
• Orders received
• Follow‑up actions
• Reassessment
✔ Identify Failures
• No documentation
• Vague documentation (“provider aware”)
• Contradictory entries
• Late entries
• No documentation of follow‑up
GLOBAL COMMUNICATION RED FLAGS
• “Provider aware” with no details
• No documentation of provider notification
• Delayed callback
• No reassessment after new orders
• Family not notified of deterioration
• No communication between disciplines
• Contradictory handoff information
• Missed or incomplete handoffs
• No documentation of escalation steps
• No follow‑up after abnormal labs or vitals
These are some of the strongest breach indicators in healthcare negligence cases.