The faculty today could not have been more explicit in the role that communication has in patient safety. As John Nance effectively displayed by a show of hands, there have been virtually no medical errors that have not had some type of communication breakdown.

So where does this leave me, the staff nurse, who wants to identify ways to improve communication in my own practice? A moment of brainstorming and I see multiple opportunities in which I can and should do better. No longer should it be acceptable for me to receive verbal orders from physicians as they are running down a hallway with me chasing after them, no longer should I accept RN to RN reports at the loud and busy nursing station that should be conducted at the bedside, and the list goes on.

Ultimately, my hospital has communication standards in place and it is no longer acceptable for me to ignore them. As I learn about the standardization of deviance, the gravity of this situation is made all the more apparent. This seemingly innocuous deviation could be a contributing link in a chain of events that lead to a catastrophic patient outcome.

Before this conference, QI and safety projects, were the ways in which I had thought I could bring about real change in my institution. Though these projects have merit, I missed the importance of self-evaluation that would have enabled me to realize the importance of change that needs to occur in my own practice. This starts with my firm belief and commitment to upholding communication standards and modeling appropriate behavior.