Table 4
Miscommunication Incidents Captured During Clinical Rounds
| Incident* | Mechanism | Distributed Cognition† | Excerpt | Consequence |
| Dose misread | Handwriting misinterpreted | artifacts | “mistakenly read the dose of her meds” (medications) | Medication overdose prescribed |
| Whiteboard uninterpretable | Handwriting misinterpreted | artifacts: whiteboard | “PKA” (reference unclear) is that for Ketones? I believe that says “PKG” (package) | Corrected on round |
| Whiteboard uninterpretable | Handwriting un-interpretable | artifacts: whiteboard | “Is she going home? I can’t read that” | Corrected on round |
| Medicine: no response to page | Information inaccessible | space | “paged (doctor), but she didn’t return my page” | Indeterminable |
| Medicine wants reassessment | Information lost in transmission | space | “guess the information had not been transmitted well” | Repeated work: re-evaluated |
| Lost relative’s phone number | Information discarded | artifacts: notes | “umm… I may have thrown away my notes” | Repeated work: find number |
| No sign-out given at shift change | Information lost at shift-change | teams, time | (doctor name)’s sign-outs are never great | Indeterminable |
| Lost note: patient refused meds | Information inaccessible | artifacts: notes | “may be some note that he didn’t take his medication” | Decision delayed |
| Dubious diagnosis, source unknown | Degradation across time | time | “along the way she picked up a diagnosis of Parkinson’s” (Disease) | Wrong meds prescribed (medications) |
| Patient restriction not communicated | In file, but not communicated | team, artifacts | “how come I don’t know about it?” | Decision delayed |
| Quantity of Ativan received unknown | Information inaccessible | space | “don’t know how much Ativan she got in (medical area)” | Indeterminable |
