Communication failures were a factor in 30% of medical malpractice cases examined as part of a recent study of medical malpractice conducted by CRICO Strategies. The study analyzed 23,658 malpractice claims from 2009 to 2013. Most significantly, the report found that a full 30% of the cases involved communication errors, and 1,744 of those cases resulted in death. While the data in the report only covers about one-third of all paid malpractice claims, the cases are representative of hospitals and clinicians’ offices across the country. Researchers identified over 7,000 cases where communication failures between clinicians or between medical staff and patients resulted in harm to patients.
While electronic health records (EHR) have been viewed as a way to avoid errors, the study found that they sometimes have the opposite effect – if information is entered but not flagged, a clinician may not notice it. The study gave the following example: a woman’s cancer diagnosis was delayed for a year because when the lab result was entered into the EHR, it was not flagged for her primary care provider. Another EHR failure took place when a primary care provider referred a patient to a lung specialist but didn’t mention that lab results signaled possible early congestive heart failure. The primary care provider assumed that the specialist would see the lab results in the EHR, but he did not. The patient died 9 days later after his lungs filled with fluid.
Other cases involve lack of communication – for example, not conveying vital information. One such case involved a woman who asked to have her tubes tied after giving birth via a Cesarean section. The instructions were not conveyed to the obstetrician on duty, so the procedure was never carried out. However, the patient believed that she was no longer able to conceive. When she became pregnant again, a malpractice suit was filed.
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In another communication gap, a patient with diabetes left repeated messages with her clinician’s office, but they were not conveyed to the clinician. Since the clinician was not notified of the calls, he did not call the patient back. She later collapsed and died from diabetic ketoacidosis. The study examined challenges to proper communication, such as constant interruptions, heavy workload, and poorly-designed EHR systems, but it also highlighted possible solutions, such as a program called I-PASS which began in Boston Children’s Hospital in 2008 and is now being used in 32 other hospitals.
