Communication Breakdown the Cause of Many Patient Injuries, Death

Patient safety has become a major focus for hospitals in recent years. Risk management and patient safety officials are tasked with implementing initiatives that reduce physician and staff errors, including everything from proper labeling of specimens to medication safety and counting of supplies following surgical procedures. Great strides have been made as a result of these efforts, but a startling 80% of all medical errors involve  miscommunication between providers. The average patient in a hospital will see between 3-4 physicians during their stay, allowing ample opportunity for vital information to simply slip through the cracks. In an Medscape article published last year, the author refers to a 2015 review conducted by the company that insures Harvard-affiliated hospitals.  After looking at nearly 24,000 medical malpractice claims against Harvard-affiliated facilities, they found that 30% of the cases involved a communication gap between providers. Those 24,000 claims paid out $1.7 billion to victims, 1700 of which involved a death.

According to an assistant vice president for the insurance firm, CRICO,  “Errors often occur because information is unrecorded, misdirected, never received, never retrieved, or ignored. Every mode and system by which patients and caregivers share health-related information is vulnerable to failure.” According to the review’s results, more often the not, the communication breakdown occurs between providers, not between the provider and the patient.

Who’s Responsible When Information Goes Missing?
There are so many opportunities for things to go wrong when a patient changes hands. The CRICO review revealed numerous cases in which information was not relayed to the next physician in the chain of command. Some of the examples included failure to notify the primary care physician of test results revealing cancer, which resulted in a yearlong delay in a patient’s diagnosis, as well as another case involving failure to notify an on-call obstetrician that a patient had requested to be sterilized. The patient later became pregnant. When a patient is injured or dies as a result of medical error, the major question is always who is responsible. If one physician or caregiver fails to give all relevant information to the next person in the chain, who is to blame? The answer? Only a skilled medical malpractice attorney can help determine who is truly at fault.

The Medscape article quotes Rick Boothman, the Chief Risk Officer at the University of Michigan Health System. Mr. Boothman says, “There’s been a growing attention to how the organizational culture affect the risk at the handoff. Hierarchical cultures are likely to have greater problems because staff are afraid to ask questions. Residents may be afraid to appear uninformed or even stupid if they raise issues.” If a nurse, medical resident, or other physician is intimidated by a more senior doctor, the fear of retaliation or humiliation can prove to be injurious or even deadly to a patient. Experts have seen that implementation of policies that encourage open dialogue between nurses and physicians, as well as detailed instances of when nurses should call physicians with patient concerns can cut down on tragedies.

Electronic Medical Records: A Lifesaver?
Another important questions is how the medical profession can stop these errors in communication from happening. One often-proposed solution is the use of streamlined electronic medical records (EMR). The ability for a primary care physician to be able to access the same records as a specialist or hospital-employed physician (called a Hospitalist), could help cut down on errors in the transfer of information. In an EMR, everything from medications, previous doctor visit history, test results, and physician notes become shared property, allowing for constant sharing of relevant information and potentially reducing instances of communication breakdown. However, industry safety experts aren’t so confident in this solution. In an era where ‘paperwork’ has begun to cut into valuable patient time, many doctors are put off by having to enter every single detail of a patient encounter into an EMR. Experts also say that with so much information piled into each record, there can be a sort of data overload, leading to things still being missed. Also lacking is the human element. The days of sitting together and discussing patient cases have dwindled, with many providers now adopting the mentality that if it was put into a patient’s record, everything should be taken care of.

There is one potential fix that is hard to find fault with. According to Darrell Ranum of The Doctors Company, “Some hospitalist groups are sending discharge summaries to primary doctors and making themselves available for a conversation. The groups are also conducting follow-up calls to patients after discharge to make sure that patients understand instructions, to answer questions about treatments or medications, and to inquire about their recovery.” The initiative taken by physicians to work with both their patients and their primary care doctor after discharge can prove to be lifesaving. Sometimes the best solution is the simplest one.

If you or someone you love has been injured as the result of a medical error, figuring out where things went wrong and determining liability can be extremely complex. The medical malpractice attorneys of Levin and Perconti have over 130 years of combined medical malpractice experience and have been a force in courtrooms throughout Illinois for over 30 years, achieving nearly $700 million in verdicts and settlements. Our attorneys are committed to finding the truth and securing the best possible result for you and your loved ones. Please, contact us for a free consultation by calling 312-332-2872 or completing our online case evaluation request form.


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