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. By mapping communication pathways and identifying failures, this tool allows you to reconstruct the information flow and expose critical breakdown points that shape liability, causation, and credibility in healthcare litigation.

This tool is essential during case screening, timeline reconstruction, breach analysis, and deposition preparation. Use it to uncover hidden failures that directly influence the outcome of your case.

Communication Pathways Overview

Identify all communication channels and map the expected vs. actual pathways to uncover missed or delayed steps.

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)

Red Flags / Breach Indicators

  • Missing or delayed steps in communication pathways
  • Expected communication that did not occur
  • Failure to escalate communication at critical points

Provider Notification Mapping

Track key provider notifications, including changes in condition and abnormalities, while identifying failures to communicate critical updates.

Key Notifications to Track

  • Change in condition
  • Abnormal vitals
  • Abnormal labs
  • New symptoms
  • Medication issues
  • Falls or injuries
  • Wound deterioration

Red Flags / Breach Indicators

  • No provider notification
  • Delayed notification
  • Incomplete information provided
  • No follow-up after notification
  • Provider unaware of deterioration

Interdisciplinary Communication

Map communication between staff members to identify failures in critical interdisciplinary collaboration.

Communication Between Staff

  • Nurse ↔ Therapist
  • Nurse ↔ Aide/CNA
  • Nurse ↔ Charge Nurse
  • Nurse ↔ DON
  • Nurse ↔ Pharmacy
  • Nurse ↔ Social Worker

Red Flags / Breach Indicators

  • 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 with family and caregivers regarding changes in condition, symptoms, and care plan updates.

Required Communication

  • Change in condition
  • New symptoms
  • Falls or injuries
  • Transfers
  • Medication changes
  • Care plan updates

Red Flags / Breach Indicators

  • Family not notified
  • Delayed notification
  • Incomplete or inaccurate information
  • No documentation of communication

Transfer & Handoff Communication

Ensure required handoff elements are documented and that no communication breakdowns occur during transfers between care settings.

Required Handoff Elements

  • Reason for transfer
  • Vitals
  • Labs
  • Medications
  • Recent changes in condition
  • Interventions performed
  • Pending orders
  • Safety risks

Red Flags / Breach Indicators

  • Missing handoff
  • Incomplete handoff
  • Contradictory information
  • No documentation of communication with receiving facility

Escalation Failure Mapping

Track steps involved in escalation, including recognition of deterioration, notification, and intervention, while identifying failures at each stage.

Escalation Steps to Track

  • Recognition of deterioration
  • Notification of charge nurse
  • Notification of provider
  • Interventions ordered
  • Reassessment
  • Transfer decision
  • EMS activation

Red Flags / Breach Indicators

  • No escalation despite red-flag symptoms
  • Delayed escalation
  • Escalation to the wrong person
  • No reassessment after escalation
  • No follow-up after new orders

Documentation of Communication

Review documentation for time stamps, who was notified, what information was provided, and follow-up actions taken to ensure all communication is properly recorded.

Key Documentation Elements

  • Time of communication
  • Who was notified
  • What information was provided
  • Orders received
  • Follow-up actions
  • Reassessment

Red Flags / Breach Indicators

  • No documentation
  • Vague documentation (“provider aware”)
  • Contradictory entries
  • Late entries
  • No documentation of follow-up

Global Communication Red Flags

These are the strongest breach indicators across healthcare communication failures.

  • “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

Communication Failure Mapping Exposes Missed Warnings

Many healthcare liability cases turn on whether critical information was properly communicated, escalated, and acted upon. This tool reconstructs information flow across clinicians, supervisors, physicians, facilities, and external providers to identify breakdowns that contributed to adverse outcomes. Our clinical-legal team maps notifications, handoffs, missed escalations, delayed responses, and documentation gaps to clarify regulatory exposure, causation pathways, and litigation strategy.

Ready to Strengthen Your Case?

Leverage the **Communication Failure Mapping Tool** to uncover hidden communication breakdowns and missed escalation points that impact patient outcomes and litigation strategy.