Communication failures continue to plague patient care. Experts weigh in on why nearly one-third of malpractice claims involve a communication failure, leading to significant patient harm
For nearly two decades, communication failures have been frequently attributed to harmful events in healthcare. Judging by a new report looking at malpractice claims, those problems aren’t getting any better.
The report, published in January by CRICO Strategies, a division of The Risk Management Foundation of the Harvard Medical Institutions Inc., analyzed 23,000 medical malpractice claims filed between 2009 and 2013 in which patients suffered some degree of harm. Researchers found that more than 7,000 cases featured at least one kind of communication breakdown and 44% of those cases resulted in high severity patient injuries or death. Nearly 60% of communication failures involved two or more healthcare providers, and 55% involved a miscommunication with the patient.
Although communication errors are not solely to blame for patient harm, they often serve as the catalyst to subsequent missteps, says Dana Siegal, director of patient safety for CRICO Strategies in Boston.
“To be quite honest, an error is very rarely a single missed step or missed event, it’s a matter of multiple missteps lining up,” she says. “There is a miscommunication and someone doesn’t recognize it and that leads to a decision not to do a test which leads to a misdiagnosis.”
For many healthcare experts, these statistics merely add to the overwhelming evidence that miscommunication continues to plague healthcare. A recent Institute of Medicine (IOM) report entitled Improving Diagnosis in Healthcare highlighted communication as a key focus area for providers (see “IOM report highlights long-standing concerns surrounding diagnosis,” in the December 2015 issue of Patient Safety Monitor Journal). More than 15 years ago, IOM’s landmark To Err Is Human report identified communication failures as a contributing factor to patient harm.
“I’m disappointed that we continue to have the same problems,” says Frank Federico, RPh, vice president of the Institute for Healthcare Improvement (IHI). “We’ve been working on trying to improve communication for some time. Communication is the currency of healthcare; that’s how we exchange information. We have to be able to know we have good systems in place and that we have good mechanisms in place.”
By digging deeper into why and how communication failures occur, healthcare organizations can refine their approach to information exchange. Patient Safety Monitor Journal spoke with four patient safety experts about why communication failures occur so often in healthcare and what hospitals can do to reduce miscommunication.
This is an excerpt from the April issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.