OnPage CEO Cautions Hospitals: Message Delivery Is Not Proof of Clinical Accountability

Judit Sharon calls on hospitals to ensure urgent clinical communications reach the right clinician or role, command attention, provide visibility into receipt and ownership, and escalate when unanswered.

Key Takeaways

• Message delivery does not prove clinical accountability. A delivered message cannot confirm that the correct clinician accepted responsibility, responded in a timely manner, or completed the required clinical action.
• Urgent alerts require persistence, confirmed receipt, visibility, and escalation. Hospitals should use persistent, distinct notifications that override phone silent settings, provide visibility into who read and took ownership of the alert, and automatically escalate time-sensitive alerts that remain unanswered.
• Accurate, centralized on-call information is essential to patient safety. Real-time coverage data should provide a single source-of-truth for shift changes, substitutions, service assignments, and escalation responsibilities, so alerts reach the accountable clinician.
• Manual workarounds create avoidable risk. Hospitals should not rely on staff to resend alerts, check disconnected schedules, or use personal knowledge to compensate for fragmented communication systems.
• Hospitals should measure the complete path from alert to action. Clinical communication systems should document correct routing, confirmed acknowledgment, timely escalation, and the clinical action taken—not merely whether a message reached a device.

WALTHAM, Mass., Aug. 13, 2026 /PRNewswire/ -- Hospitals risk creating a false sense of patient safety when they treat successful message delivery as proof that an urgent clinical alert was handled, according to Judit Sharon, CEO of OnPage, a provider of an advanced, secure critical communication and collaboration platform that ensures urgent alerts are never missed.

Clinical communication accountability requires hospitals to verify that an urgent alert reached the correct clinician, drew their attention promptly, received confirmed acknowledgment, triggered escalation when unanswered, and resulted in documented clinical action with a clear audit trail of all the steps.

Communication breakdowns remain a major source of patient harm, even as hospitals invest heavily in secure digital communication tools and care team collaboration solutions. Candello's 2025 analysis found that communication failures were involved in 40% of asserted medical professional liability cases, up from 30% a decade earlier. In clinical communication, breakdowns can include incorrect routing, outdated on-call information, unacknowledged or missed alerts, delayed escalation, and failures to document who accepted responsibility.

Yet malpractice data capture only the incidents that become formal claims. Research summarized by the Agency for Healthcare Research and Quality indicates that just 2% to 3% of negligent injuries result in a malpractice claim. Together, the findings suggest that malpractice claims may capture only a portion of the communication breakdowns occurring across healthcare.

In her newly published article, In Clinical Communications, "Message Delivered" Doesn't Mean "Patient Safe," Sharon identifies a central patient safety weakness in hospital communication systems: technical confirmation that a message was delivered does not prove that the accountable clinician received it, accepted responsibility, or acted on it.

Sharon argues that delivery receipts alone cannot establish whether an urgent communication reached the accountable clinician, prompted a timely response, or escalated when unanswered.

Message delivery confirms transmission. Clinical communication accountability confirms that the correct clinician noticed it, accepted responsibility, responded within the required timeframe, and completed or escalated the necessary action.

"Critical communication should never be a send-and-wait process," Sharon said. "Hospitals need to know that an urgent alert reached the right on-call clinician or role, that someone took ownership and responded in time, and that the entire event can be reconstructed afterward with timestamps. When that chain breaks, it is not merely a communication failure. It is a failure of clinical accountability."

Why Doesn't Message Delivery Prove Clinical Accountability?

Message delivery proves only that a communication reached a device or application. It does not prove that the correct clinician, on-call group, or clinical role heard the alert, accepted responsibility, responded in a timely manner, or initiated the required care.

For high-risk clinical events, hospitals need persistent, distinctive alerts that can override silent mode and Do Not Disturb settings, require confirmed acknowledgment, enable automated escalation, provide a single source-of-truth for real-time on-call coverage, and maintain a clear record of whether an accountable clinician accepted responsibility.

Acknowledgment confirms that a clinician received and accepted the alert. Response measures whether the clinician acted within the required timeframe. Clinical resolution documents what action was taken and what happened next.

"The relevant question is not, 'Was the message delivered?'" Sharon said. "The relevant question is, 'Did the communication reach the accountable clinician, did they hear it, was responsibility accepted, did escalation occur when necessary, and can the organization reconstruct the event afterward with an audit trail?'"

The risk applies to time-sensitive communications involving critical laboratory results, sepsis and STEMI alerts, rapid-response notifications, patient-monitor alarms, nurse-call escalations, pharmacy issues, and after-hours patient calls.

In each workflow, missed or incorrectly routed alerts, delayed acknowledgment, unclear ownership, or failed escalation can postpone diagnosis, treatment, or follow-up.

Outdated On-Call Information Can Misroute Urgent Alerts

Sharon also warns that fragmented or outdated on-call schedules can undermine otherwise effective communication systems. When coverage information is spread across directories, spreadsheets, answering services, and disconnected platforms, an urgent alert may be delivered successfully yet still reach the wrong clinician.

Accurate on-call routing requires a continuously updated source of coverage information natively built into the clinical communication platform that accounts for shift changes, substitutions, service assignments, and escalation responsibilities. It should also integrate with and synchronize coverage data from existing workforce management, HR, or enterprise scheduling systems when those platforms remain the hospital's primary system of record.

Hospitals should incorporate real-time coverage changes into alerting and escalation workflows, so urgent communications reach the clinician or role accountable at the time of the event.

Alerting systems should use that coverage information automatically rather than requiring staff to consult separate directories, spreadsheets, or answering services.

Clinical communication platforms should also interoperate with existing systems so urgent events from multiple sources enter the same routing, acknowledgment, escalation, and audit workflow.

Manual Workarounds Are Not a Reliable Safety Net

Disconnected systems often force nurses, operators, physicians, and department leaders to resend alerts, check separate schedules, or rely on personal knowledge to find the correct clinician.

"Staff persistence matters, but it should not be the safety net," Sharon said. "A hospital should not depend on individual heroics to ensure that an urgent clinical event receives a response."

What Steps Should Hospitals Take to Strengthen Clinical Communication Accountability?

Sharon recommends that hospitals strengthen clinical communication accountability by taking six immediate steps:

• Audit high-risk clinical communication workflows to identify failures in routing, acknowledgment, and escalation.
• Maintain accurate, real-time on-call coverage so every urgent alert reaches the clinician or role responsible at the time of the event.
• Use persistent, distinguishable high-priority alerts that require confirmed acknowledgment, and automatically escalate urgent alerts that remain unanswered.
• Measure communication performance using acknowledgment times, response times, unresolved alerts, escalation frequency, routing errors, and after-hours delays.
• Document responsibility and response by recording who was accountable, whether responsibility was accepted, and what occurred when no one responded.
• Preserve an auditable communication record so each urgent event can be reconstructed for clinical review, quality improvement, and accountability.

Hospitals should evaluate urgent communication systems based on five outcomes: attention-commanding critical alert delivery; correct routing; confirmed acknowledgment; timely escalation; and documented clinical action. Message delivery alone does not confirm any of those outcomes.

A message reaching a device does not prove that the right clinician noticed it, took responsibility, or that the patient received timely care. Hospitals need communication systems that document the full path from alert delivery to clinical action.

To read the full article, visit: https://www.linkedin.com/pulse/clinical-communications-message-delivered-doesnt-mean-judit-sharon-s66zc/.

Frequently Asked Questions 

Who should be responsible for improving clinical communication accountability across a hospital?
Clinical communication accountability should be shared across clinical leadership, patient safety, quality, risk management, and information technology, with one leader responsible for coordinating improvements. OnPage supports this cross-functional approach by providing visibility into critical alert routing, acknowledgment, escalation, and response activity.

How should hospitals test urgent clinical communication workflows under real-world conditions?
Hospitals should test urgent clinical communication workflows by simulating unanswered alerts, routing errors, schedule changes, after-hours coverage, and system disruptions. OnPage supports more reliable workflows through persistent alerting that overrides the silent switch and DND settings, precise on-call management, automated escalation, and real-time communication insights.

How can hospitals connect clinical communication accountability with existing communication workflows?
Hospitals can strengthen accountability in clinical communication by replacing disconnected schedules, directories, and manual routing processes with a unified communication workflow. OnPage combines secure messaging, persistent alerting, automated escalation, and precise on-call management to help urgent communications reach the appropriate clinician faster.

How can hospitals strengthen accountability for clinical communication without increasing the burden on clinicians?
Hospitals can reduce the burden on clinicians by distinguishing routine messages from urgent events. OnPage unifies communications from connected systems, staff-initiated pages, and after-hours calls, delivering routine messages with a standard, non-intrusive notification tone while urgent alerts use distinctive, persistent notifications. Real-time on-call routing and automated escalation help ensure each alert reaches the appropriate clinician, group, or role without manual follow-up.

About OnPage

OnPage Corporation empowers healthcare organizations and IT teams to significantly improve their event detection and response with an advanced, secure critical communication and collaboration platform. By unifying automation, secure messaging, collaboration and real-time analytical insights, OnPage's purpose-built platform supports complex workflows with unmatched precision and ensures that urgent alerts are never missed. For healthcare organizations, OnPage offers an all-in-one, HIPAA-compliant clinical communication platform designed to accelerate response times, improve coordination, enhance patient outcomes and reduce risks. For IT teams, OnPage provides an automated incident alert management and on-call scheduling platform, streamlining incident response by delivering persistent, real-time alerts to the right on-call engineers, reducing mean time to resolution and boosting operational efficiency. OnPage's solutions are widely adopted across various industries, including healthcare, IT and managed services, manufacturing and field services. Founded in 2011, OnPage is certified as a Women's Business Enterprise (WBE) by the Center for Women & Enterprise, a regional partner of the Women's Business Enterprise National Council, and actively champions women-owned businesses to drive impactful change. For more information, visit https://www.onpage.com.

Media contact: 
Michael Tebo 
Gabriel Marketing Group (for OnPage Corporation)
Email: [email protected]

SOURCE OnPage Corporation