Welcome  to  the  Public  health  moment from  the  University  of  Minnesota. Bill  Riley,  a  health  care  management professor  at  the  University  of  Minnesota, is  working  with  hospitals  to  develop training  to  improve  patient  safety. How  by  reducing  errors  caused by  breakdowns  in  hospital  communications. There's  a  large  body  of  evidence  in the  healthcare  safety  research  literature  that indicates  that  the  bulk  of  sentinel  events and  patient  injury  is  caused  by  communication  errors. In  our  research,  we  are  finding  that  there  are very  predictable  patterns  of communication  errors  that  we  are  detecting. One  example  Riley  cites  is a  failure  to  close  loops  in  communications. Probably  the  pattern  that  is  most surprising  to  us  is  what  we call  lack  of  closed  loop  communication. Where  a  provider  will  issue  an  order  for  patient  care, The  orders  are  not  acknowledged. And  because  they  are  not  acknowledged, there  are  times  when  they  do  not  get transmitted  using  simulation  equipment. Riley  is  testing  ways  to  improve  communications. What  we  are  assessing  and training  for  is  how  can  they  all  work  together  as  a  team? And  that  is  probably  one  of the  biggest  challenges  that  we  have  in  healthcare, is  to  make  a  team  of  experts  to  mold themselves  into  an  expert  team with  another  public  health  moment. I'm  John  Finnegan.