The Prime Directive


Skilled communication is one of the most elusive competencies to master. However, when the focus is patient safety, it is the prime directive for organizational excellence. The two documents that have been personally highly applicable in this author’s clinical practice are the research reports called Silence Kills (Maxfield et al., 2004) and Dialogue Heals (Maxfield et al., 2008). The full reports are available as a pdf download at if an email address is registered.

These reports focus on seven categories of conversations that are both challenging and perceived by most healthcare professionals as “risky”. These categories represent the problems in communication that lead to poor patient outcomes (Maxfield, 2004).
•Broken Rules
•Lack of Support
•Poor teamwork
Maxfield et al., (2004) call the inability to communicate in these circumstances as a choice not to have a crucial confrontation. Addressing these problems in rural healthcare environments can present with an additional level of complexity, due to the financial interconnectivity of only a small group of providers.

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