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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






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






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