Patient Safety Tip of the Week

December 11, 2007                Communication…Communication…Communication




This week we’ll discuss three recent articles highlighting issues with communication. We know that breakdowns in handoffs and a variety of communication are contributing events in almost 70% of sentinel events reported to Joint Commission and we know from doing many root cause analyses that we can find some sort of problem with communication among care providers almost every event with an adverse outcome.



In our October 23, 2007 Tip of the Week on Medication Reconciliation Tools, we mentioned that, while there are statistics on the error rates for medication reconciliation at admission and discharge, there have not been good statistics on errors in medication reconciliation at the time of internal transfers within hospitals. In the December 2007 Journal of Patient Safety, Grant and Larsen(1) report on a study on clinical information transfer and medication reconciliation in patients transferred from pediatric intensive care units at a pediatric tertiary care center. Overall, in 75% of the transfers there was at least one missed order (i.e. an order for either care or a medication) and 30% had 2 or more missed orders. They calculated a rate of 11.7 missed medication orders per 100 medication orders and 6.8 missed patient care orders per 100 patient care orders. That study was done before the hospital had implemented a formal medication reconciliation process that includes use of computer-generated reconciliation forms.



The second paper by Matheny et al. (2) was in the November 12, 2007 issue of the Archives of Internal Medicine entitled “Impact of an Automated Test Results Management System on Patients’ Satisfaction About Test Result Communication”. It describes an automated system at Partners Healthcare in Boston for generating letters to patients regarding laboratory test results. The physician sees a test results summary page and has the opportunity to acknowledge the test result and generate and document patient notification letters. They did a before and after comparison of patient satisfaction with results notification and had a control group that did not use the automated system. They demonstrated that there was an improvement in patient satisfaction with results notification in the group utilizing the automated sytem but no change in the control group. They also demonstrated that these patients were more likely to be satisfied with the amount of information given them about the conditions and treatments related to those test results.



And a report by Kate Madden Yee(3) on presentations at the 2007 Radiological Society of North America noted 3 presentations that used high-tech communications tools to improve patient care. That report, by the way, is from the website which is a very useful radiology site with up-to-date news on events related to radiology and loads of useful clinical information often related to patient safety. Ensuring that significant abnormal findings be communicated to referring physicians and subsequently to patients is often problematic (see our May 1, 2007 Tip of the Week The Missed Cancer). The Massachusetts General Hospital has developed a good solution. It integrated a communication tool with the existing IT infrastructure (we don’t know if it was part of the system referred to in the Matheny paper cited above). When a radiologist highlights important results with a specific phrase recongnized by the system, the system generates an e-mail alert to the referring physician. If the e-mail is not acknowledged, a fax with the information is sent to the referring physician’s office.



The Yee report also noted a presentation in which paper radiology request slips were scanned into the system so radiologists could read the request directly rather than just the information manually typed into the computer system. They found 62% of the reviewed cases had discrepancies between the written request and the computerized request, many of which included clinically important information. The third presentation in Yee’s report was about how a confidential web-based QA reporting system allowed non-radiology physicians to communicate radiology quality issues back to the radiology department. The hospital found this a very useful tool to drive some of their quality improvement processes.





  1. Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care Unit. J Patient Saf 2007; 3” 195-199


  1. Matheny ME, Gandhi TK, Orav EJ, et al. Impact of an Automated Test Results Management System on Patients’ Satisfaction About Test Result Commumication. Arch Internal Med 2007; 167: 2233-2239


  1. Yee KM. High-tech communication tools improve patient care, studies find. Accessed from the web site 12/6/2007.









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