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What’s New in the
Patient Safety World
February 2022
Communication
Failures and Malpractice
It should come as no
surprise that communication issues are a major contributor to malpractice
claims, since communication issues are contributing factors in the majority of our root cause analyses into serious adverse
events. But there has been little actual data published on the role of
miscommunication in malpractice claims.
In a new study researchers
reviewed a random sample of malpractice claims from 2001 to 2011, collected in
CRICO Strategies’ Comparative Benchmarking System, a national claims database (Humphrey
2021). They identified communication failures in 49% of claims. Moreover, claims
with communication failures were significantly less likely to be dropped,
denied, or dismissed than claims without (54% versus 67%, P = 0.015) and
total costs were higher for those claims with communication failures. Of those
claims with communication failures 53% involved provider-patient miscommunication
and 47% involved provider-provider miscommunication. Communication errors among
medical staff most often occurred between the attending physician and the
nursing staff (37%), attending physicians between specialties (30%) and within
a specialty (19%). Specific information types most frequently identified were
contingency plans, diagnosis, and illness severity. The researchers found that 40%
of communication failures involved a failed handoff and that 77% could
potentially have been averted by using a handoff tool.
The focus on handoffs is also not surprising, since the
senior author of the study was Chris Landrigan, M.D.,
M.P.H., Co-Founder of the I-PASS
Patient Safety Institute, whose work we have highlighted in our many
columns on handoff issues (listed below). Handoffs occur between multiple types
of healthcare providers and always represent potential opportunities for error.
Handoffs should be done using structured formats, such as I-PASS or one of the
other tools highlighted in the columns below. But equally important, handoffs
should be conducted in a venue in which interruptions and distractions are
minimized, ample time is allotted, and the receipient
of the handoff is an active participant, asking questions and acknowledging
important points.
Read about many other
handoff issues (in both healthcare and other industries) in some of our
previous columns:
May 15, 2007 “Communication,
Hearback and Other Lessons from Aviation”
May 22, 2007 “More
on TeamSTEPPS™”
August 28, 2007 “Lessons
Learned from Transportation Accidents”
December 11,
2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The
Hospital at Night”
September 30, 2008 “Hot
Topic: Handoffs”
November 18, 2008 “Ticket
to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another
Good Paper on Handoffs”.
June 30, 2009 “iSoBAR:
Australian Clinical Handoffs/Handovers”
April 25, 2009
“Interruptions,
Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff
Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012
“Handoffs
– More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving
Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to
OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative
Handoff”
March 2017 “Adding
Structure to Multidisciplinary Rounds”
August 22, 2017 “OR
to ICU Handoff Success”
October 2017 “Joint
Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital
Transfers”
April 9, 2019 “Handoffs for Every Occasion”
November 2019 “I-PASS Delivers Again”
August 2020 “New
Twist on Resident Work Hours and Patient Safety”
September 29, 2020 “ISHAPED for Nursing Handoffs”
May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
References:
Humphrey KE, Sundberg M, Milliren
CE, et al. Frequency and Nature of Communication and Handoff Failures in
Medical Malpractice Claims. Journal of Patient Safety 2021; December 15, 2021 -
Volume - Issue -
I-PASS Patient Safety Institute
https://www.ipassinstitute.com/
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