Preventable Medical Errors During Patient Handoffs

Miscommunication among healthcare providers during hospital patient handoffs can lead to serious medical errors and patient harm. What should be done to ensure good communication during this key transitional period of medical care?

Miscommunication is a significant factor in preventable medical errors. CIRCO Strategies, a medical malpractice insurance provider, reviewed 23,000 closed medical malpractice lawsuits and found nearly a third involved a communication failure or breakdown among healthcare providers.

Another medical malpractice insurance provider, Coverys, in 2021 reviewed medical malpractice lawsuits involving care transitions. Its findings showed that:

• 45% of the medical care transition error lawsuits involved the death of the patient
• 14% of the medical care transition error lawsuits involved high-severity patient injuries

The Joint Commission is an agency that accredits hospitals. It concluded that 80% of errors made during patient handoffs – a period of transitional care when one shift of medical providers replaces another – are related to poor communication.

Important treatment and patient information is relayed from one set of providers to another during patient handoffs. Clear, thorough and understood communication during this transition is essential to ensure a proper continuity of care.

How to Prevent Medical Treatment Communication Errors

The Joint Commission has eight recommendations for avoiding communication mistakes, and potentially serious patient harm, during patient handoffs.

The first step is to establish the information most critical to be communicated, as well as which information should be given face-to-face and which information can be written down.

Another key is to have standardized methods in place for conducting patient handoffs. Most essential is consistently employing the right tools that ensure receiving treatment shifts have all the information they need.  These communication tools include:

• Safety checklists
• Patient summaries
• Information templates

While many of these tools involve paper or electronic communications, The Joint Commission’s blueprint for preventing communication errors during patient handoffs emphasizes the need for personal communication.  This includes face-to-face as well as phone calls or video chats.

Involve All Providers, and Patients and Families, in Handoff Communication

Personal communication allows for the receiving treatment staff to ask questions that can better help avoid misunderstandings or confusion. When conducting face-to-face communication during patient handoffs, it should be in designated locations that typically are free from distractions or interruptions.

Medical treatment can be complex, involving many data points as well as providers.  The Joint Commission recommends that all information during patient handoffs be combined and presented at one time. When key information is provided incrementally, some vital details may get overlooked.

Minimum Information to Include in Patient Handoff Communication

To ensure the receiving medical staff has all the information they need to provide a continuity of care, communication during patient handoffs should include a minimum of items that include:

• The medical care sender contact information if any follow-up is required
• To-do action list
• Treatment contingency plans
• List of patient allergies
• List of patient medications
• Dated laboratory tests

Patient handoffs also should include patients and their families, according to The Joint Commission.  This allows them to provide potentially valuable feedback and ask questions of both sets of healthcare provider teams.

Patients should expect to receive an appropriate standard of care during medical treatment, even when different providers are involved.  Communication mistakes made during patient handoffs are potentially very dangerous, and can lead to substandard care that needlessly endangers patients.

If you believe you or a loved one was a victim of serious error during medical treatment, a personal injury lawyer can conduct a detailed investigation on your behalf to bring all responsible parties to account.

The choice of a lawyer is an important decision that should not be based solely on advertisements.

Authored by Gray Ritter Graham, posted in Articles July 12, 2022