Malpractice Report Finds Hospital Miscommunication Costs $1.7 Billion

Nearly 2,000 patients died over five-year period

Hospitals and doctors’ offices nationwide might have avoided $1.7 billion in malpractice costs––and nearly 2,000 patient deaths––if medical staff and patients communicated better, according to an article posted on the STAT website.

A report from CRICO Strategies, a research and analysis offshoot of the company that insures Harvard-affiliated hospitals, found that communication failures were a factor in 30% of malpractice cases filed between 2009 and 2013. The cases included 1,744 deaths.

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—signs of possible internal bleeding. The patient later died of a hemorrhage.

In another case, 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.

Advocates have been pushing to improve hospital communication ever since Boston Globe health reporter Betsy Lehman died in 1994 from a chemotherapy overdose at Dana–Farber Cancer Institute, which helped to spark the national patient safety movement.

The report cites many challenges to effective communication, including heavy workloads, hierarchical workplace culture, cumbersome electronic health records (EHRs), and constant interruptions.

CRICO analysts examined clinical and legal records in 23,658 malpractice cases and identified more than 7,000 cases where communication failures, either among medical staff or between medical staff and patients, harmed patients.

The analysis found that while EHRs have emerged partly to improve communications, in some cases they have had the opposite effect. For example, one woman’s cancer diagnosis was delayed for a year because her lab result was plugged into her EHR but was not flagged to her primary care provider.

According to the Joint Commission, a group that sets safety standards and accredits health care organizations, miscommunication among medical staff while transferring patients contributes to 80% of serious medical errors.

At Boston Children’s Hospital, a team 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 the hospital in 2008 in a pilot study sponsored by CRICO. Medical errors dropped by 23% percent when nine other pediatric hospitals implemented I-PASS. Now the method is being adopted at 32 hospitals across the U.S., including those that treat adults, such as Brigham and Women’s Hospital in Boston.

Frank Federico, vice president for patient safety at the Institute for Healthcare Improvement in Cambridge, Massachusetts, said that for patient safety programs such as 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.”

Sources: STAT; February 1, 2016; and CBS Reports; 2016.