Abstract
In 2006, JCAHO defined the second of its National Patient Safety goals as to “Improve the effectiveness of communication among caregivers”. The SBAR protocol gives practical guidelines for person-to-person communication but may not be appropriate in its current form for more complex contexts. This paper presents a case study showing communication processes in one ICU and illustrates important principles of complex clinical communication. The case study is based on observational and interview data from a bedside nurse, a charge nurse, a resident and a fellow over 12 hours each in a major trauma ICU. Artefacts were also collected and annotated. Five types of interconnected communication events are described in the sequence in which they occur. Each communication event is described in terms of its purpose, participants, process, and support tools. Four principles are defined.