Lack of Communication – The Number One Cause of Medical Errors

The Joint Commission, which accredits most hospitals in the US and many abroad, consistently identifies communication as the number one cause of medical errors. Healthcare providers are increasingly becoming aware of the opportunities for information to get lost during handoffs which often leads to medical negligence.  Handoffs occur when:

A physician turns care of his practice over to a covering doctor for a night, weekend or vacation; A nurse transfers a patient out of the recovery room to a medical-surgical unit; A primary care physician refers a patient to a specialist; A hospitalist discharges a patient back to the care of the primary physician; An ER nurse calls the intensive care unit to give report on a patient on the way to the critical care unit; A nurse tells the oncoming shift of nurses about patients under her care; A patient leaves a hospital for a nursing home.

A study in the January 10, 2011 Archives of Internal Medicine found wide disparities among primary care physicians’ and specialists’ perceptions of how often they send and receive patient information. The study showed that 69.3% of primary care physicians said they send specialists notification of patients’ history all or most of the time, while only 34.8% of specialists said they routinely receive such information.

Meanwhile, 80.6% of specialists said they send consultation results to the referring physician all or most of the time, but 62.2% of primary care physicians reported never receiving that information. Direct communication between hospitalists and primary care physicians also is rare, happening between 3% to 20% of the time, according to a study published in the Feb. 28, 2007, issue of The Journal of the American Medical Association.

What can you do as a patient about handoffs? You have little or no control over how nurses transfer information about your care when you are in the hospital.  You might become aware of change of shift report if it takes place during “walking rounds”. These take place when the nurse from the oncoming shift and the nurse from the off going shift walk to each room to discuss each patient. This form of change of shift report is believed by many to foster better communication. Some change of shift reports occur in a conference room. You may be unaware they’re occurring, except when you need a nurse during this time, and no one comes. If there is something of importance that you want the next nurse caring for you to do, ask that person directly. While you should be able to rely on the handoff process to transmit the information, we know it does not always happen.

What can you do about communication between physicians?  First, if you are in the hospital, under the care of a hospitalist, you may request the hospitalist to call your primary care physician and update him or her on your condition. Second, if you see a specialist, ask that person to write a note to your primary care physician with updated information on your condition and treatment plan.  Your request is hard to ignore. Speak up proactively for improved communication – it could save your life.

Please contact Kathleen A. Mary, RN, Certified Legal Nurse Consultant to assist you in your next medical-legal case involving medical errors.

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