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Hospitals and doctors’ offices nationwide might have avoided nearly 2,000 patient deaths — and $1.7 billion in malpractice costs — if medical staff and patients communicated better, a report released Monday has found.
Communication failures were a factor in 30 percent of the malpractice cases examined by CRICO Strategies, a research and analysis offshoot of the company that insures Harvard-affiliated hospitals. The cases — including 1,744 deaths — involve some horror stories that no family, and no medical professional, wants to experience.
In one instance, a nurse failed to tell a surgeon that a patient experienced abdominal pain and a drop in the level of red blood cells after the operation — alarming signs of possible internal bleeding. The patient later died of a hemorrhage.
In another, medical office staff received calls from a diabetic patient, but did not relay the messages to the patient’s primary care provider, so the patient never got a call back. The patient later collapsed and died from diabetic ketoacidosis, which arises when the body doesn’t have enough insulin.
In a third case, a woman asked to have her tubes tied after delivering a baby through a C-section, but her instructions were not shared with the obstetrician on duty. The patient filed a malpractice claim when she got pregnant again.
Frank Federico, vice president for patient safety at the Institute for Healthcare Improvement in Cambridge, Mass., called the findings disappointing because they suggest two decades of work has achieved too little progress. He said advocates have been pushing to improve communication ever since Boston Globe health reporter Betsy Lehman died in 1994 from a chemotherapy overdose at Dana-Farber Cancer Institute, which helped to incite the national patient safety movement.
“We’ve been working on this for a long time, and it still continues to be a big problem,” said Federico, who previously worked at CRICO as a patient safety specialist.
The report cites many challenges, such as heavy workload, hierarchical workplace culture, cumbersome electronic health records, and constant interruptions. And it highlights solutions, including a program called I-PASS born at Boston Children’s Hospital.
The data in the report aren’t comprehensive — they represent about a third of all paid malpractice claims nationwide — but come from a representative slice of hospitals and doctors’ offices across the country, said report co-author Gretchen Ruoff, senior program director for patient safety at CRICO.
Analysts examined clinical and legal records in 23,658 malpractice cases from 2009 to 2013. They identified over 7,000 cases where communication failures, either among medical staff or between medical staff and patients, harmed patients.
The report found that, while electronic medical records have emerged partly to improve communications, in some cases they have the opposite effect.
For instance, one woman’s cancer diagnosis was delayed for an entire year because her lab result was plugged into the electronic health record but was not flagged to her primary care provider.
In another case, a primary care provider referred a patient to a lung doctor but didn’t mention lab results signaling possible early congestive heart failure, assuming that doctor would see the results in the electronic medical record. About nine days later, the patient was rushed to the emergency room and died after his lungs filled with fluid.
The impact of miscommunication on medical errors is likely even greater than the report indicates, because it looked just at malpractice cases, said Dr. Christopher Landrigan, a patient safety researcher and pediatrician who directs the inpatient program at Boston Children’s.
Miscommunication among medical staff while transferring patients contributed to 80 percent of serious medical errors, according to one estimate by the Joint Commission, a group that sets safety standards and accredits health care organizations.
Landrigan is part of a team that is trying to improve communication through I-PASS, a methodical way to relay information during patient “handoffs” when doctors and nurses change shifts.
The program began at Children’s in 2008, in a pilot study sponsored by CRICO. Landrigan and his colleague Dr. Amy Starmer then showed in a New England Journal of Medicine study that medical errors dropped by 23 percent when nine other pediatric hospitals implemented I-PASS.
Now the method is spreading to 32 other hospitals in the United States, including those that treat adults, such as Brigham and Women’s Hospital in Boston’s Longwood Medical Area.
“We were doing our own work at the Brigham on how to improve handoffs, and we sort of realized that I-PASS is better,” said Dr. Jeffrey Schnipper, director of clinical research for the Brigham’s hospitalist service.
One recent evening, Schnipper took notes as five residents and interns handed off patients using I-PASS, which was introduced at the hospital last fall. I-PASS is a mnemonic device standing for: illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver.
As intern Julia Beamesderfer heard a rundown of the 17 patients she would be caring for on the twilight shift, the doctor-in-training practiced the final “s,” synthesizing the information and reading it back to her colleagues.
One patient came with special instructions: The elderly woman had just been diagnosed with metastatic cancer, but she didn’t know that yet. The question came up: Who’s going to break the news? The doctors decided who would do it, and how.
That’s one piece of information that could easily get lost in the shuffle as doctors head home after an exhausting shift. The doctors also ran through action plans, such as how much pain medication to give.
“When we’re rushed, we definitely don’t do every part of it,” Beamesderfer said of the I-PASS protocol. But she said she has found it helpful to take a more active role when receiving her caseload, rather than passively listening to instructions.
IHI’s Federico said that for patient safety programs like I-PASS to take off, hospitals have to create a culture of psychological safety, where all medical staff feel free to speak up without fear of being punished or ridiculed. And medical staff need to “speak with patients in a way they can understand,” in a way that addresses their concerns.
While some hospitals are making improvements, Federico said, those efforts are not spreading quickly enough throughout the health care system.
“We don’t have a lot of time,” he said. “We should be making care as safe as possible as soon as possible.”
To me, as a career investigator, ‘Communication Failure’ is a cause category, not necessarily a contributing factor (and certainly not a cause).
While I understand it is necessary to use such categories for trending data across a database, this type of article gives the impression that an effective investigation/analysis concludes with things like ‘communication failure’. Certainly seasoned analysts know this is not the case.
How does one write an effective corrective action for ‘communication failure’?
There is considerable more drilling down required to thoroughly understand why communication failures are occurring. We have to have a deep understanding of human performance considerations about why good people often make poor decisions. By far the majority do not intend on the bad outcomes that occur, so why did they feel it was the right decision at the time?
1. Are organizational systems in place to detect and prevent such miscommunications? Are they being followed (if not, why not)?
2. Why does staff not feel comfortable in bringing up anomalies/concerns they have to their superiors about a patient’s condition or care?
3. Do their superiors encourage or discourage such openness (and why)?
4. Has the practice of not communicating effectively evolved away from some acceptable standard, because there was no consequence for deviating from the standard?
5. Is there any oversight in place to ensure compliance with such communication’s standards?
I could go on and on, but these should make the point about how concluding with ‘communication failures’ is deficient at best from an RCA (root cause analysis) standpoint. I would also question if an RCA concludes with ‘Communication Failure’, why is that acceptable to whoever is reviewing the RCA?
I find a large source of such conclusions are deficiencies in the way RCA’s are conducted, as well as what is deemed ‘acceptable’ in terms of an RCA work product from the organization and from a regulatory audit perspective.
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