Communication Errors That Harm Patients Are Preventable
Patient Handoff

A recent review of medical malpractice lawsuits spotlighted how often communication issues are cited in serious medical error allegations - and just how frequently those issues are preventable.

Poor communication among healthcare providers can be especially dangerous during patient handoffs.  Patient handoffs occur during healthcare provider transitions.  The transitions can be when one shift of hospital caregivers replaces another, or when a patient is sent to a different medical facility or a different unit within the same hospital.

Maintaining continuity of care is paramount to ensure a patient’s safety during these transitions.

The Joint Commission, an agency that accredits U.S. hospitals, has frequently reported on the dangers of communication errors.  The agency notes previous research that found communication failures to be involved in 30% of all medical malpractice claims.

Another patient safety organization recently reported on a new medical malpractice lawsuit study that found communication failures to be common factor in medical error claims. It also identified how to prevent communication errors.

Patient Handoff Protocol to Prevent Communication Failures

The I-PASS Patient Safety Institute is an organization that developed a standardized process for gathering essential information during patient handoffs, known as I-PASS. The organization reports that its patient handoff checklist reduces medical errors by 23%.

I-PASS stands for:

Illness severity

Patient information – comprehensive summary of patient’s condition, treatment plan

Action list – timeline of further actions, responsibility for those actions

Situational awareness and contingency plans – plan for what might happen

Synthesis by receiver – ensuring that incoming medical providers understand what is being communicated

Each is an element in safe patient handoffs, according to the organization, and they should be addressed by hospitals with a standardized plan.

The I-PASS protocol was tested in nine pediatric hospitals and found to be effective in reducing patient harm from medical errors. It since has been implemented in hospitals nationwide.

In early January 2022, the organization announced the findings of a study titled “Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims.” The study was published online in December 2021 by the Journal of Patient Safety.

Allegations of Communication Errors in Medical Malpractice Claims

It reviewed nearly 500 medical malpractice lawsuits filed between 2001 and 2011 to document:

  • Instances of communication failures
  • Type of communication error
  • How preventable the errors were if the I-PASS system would have been used

According to the review, 49% of the medical malpractice lawsuits alleged communication errors. Over half of the communication failures (53%) were between doctor and patient.  The remaining 47% of the alleged communication errors were among healthcare providers.

It also found that 40% of medical malpractice lawsuits alleged communication errors during patient handoffs.  The study concluded that 77% of the patient hand-off communication errors could have been prevented if hospitals instituted a standardized process such as I-PASS.

Healthcare providers have an obligation to provide a standard level of care. When they don’t, and errors from miscommunication occur, patients and their families can suffer catastrophic harm.

If you suspect a loved one died or was seriously injured from an error during medical treatment, turn to a personal injury attorney to conduct a detailed investigation.

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

Authored by Gray Ritter Graham, posted in Blog February 11, 2022


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