Total numbers are probably higher according to new research.
Poor communications cost the U.S. healthcare system $1.7 billion in malpractice costs and nearly 2,000 lives according toCRICO Strategies research.
The 2015 Malpractice Risks In Communications report found communications breakdowns figured in 30 percent of all malpractice claims filed between 2009 and 2013. Further, 37 percent of all high-severity injury cases (including death) involved a communication failure.
The study examined7,149 cases in which facts, figures, or findings got lost between the individuals who had that information and those who needed it across the spectrum of healthcare services and settings. The report highlights the details of miscommunications and identifies specific opportunities to improve skills and systems to bridge the knowledge gaps that exist and keep everyone involved in a patient’s care fully informed in a timely manner.
Errors in communications are common across all care encounters, from interactions between providers, mismanagement of crucial information and instructions, and encounters with caregivers.Every mode and system of healthcare information-sharing is vulnerable to failure.
“Communication difficulties are not isolated to providers lacking ‘people skills’ or patients with language or comprehension deficits. Nor is the problem exclusive to communication that is misspoken or misunderstood: errors often occur because information is unrecorded, misdirected, never received, never retrieved, or ignored. Every mode and system by which patients and caregivers share health-related information is vulnerable to failure,” said Heather Riah, AVP, CRICO Strategies.
The study found 44 percent of miscommunication occurred in inpatient settings, 48 percent in ambulatory settings, and 8 percent in emergency departments. The analysis found 57 percent of cases reflected miscommunication between two or more healthcare providers, while 55 percent involved miscommunication between providers and patients and 12 percent involved breakdowns in both categories.
Common reasons for communication lapses were misinformation about a patient’s condition, ignoring a patient’s complaint, and not getting adequate informed consent, FierceHealthcare reported.
The report also found EMRs, meant to improve communication, can sometimes make it worse, according to Stat News. In one case, a woman’s lab results were captured in her EMR but not forwarded to her doctor, delaying her cancer diagnosis by a year.
While communication failures varied according to service, setting, and individuals involved, the study did find that across all settings, “miscommunication begets misinformation. If the systems that providers rely on to alert them to information gaps or discrepancies are inadequate, then misinformation can lead to mismanaged care, unmet expectations, and patient harm.”
Frank Federico, vice president for patient safety at the Institute for Healthcare Improvement in Cambridge, MA,told Stat News the findings were disappointing because they suggest two decades of work has achieved too little progress. “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.
Up to 80 percent of serious medical errors can be attributed to miscommunication among medical staff while transferring patients according to one estimate by the Joint Commission, a group that sets safety standards and accredits healthcare organizations.