Poor Communication Leads to Patient Harm in Intensive Care Units

When a handoff is fumbled in a game of football, at worst the defense recovers and returns it for a touchdown.  When a handoff is fumbled during real life critical medical care, the consequences can be fatal.

Patient handoffs – the period when a new round of care providers come on shift – are extremely important.  During this time critical information is shared about the patient’s condition and planned treatment.  They require accuracy and completeness in communicating and receiving patient information.

250,000 Avoidable Hospital Patient Deaths Per Year

Poor communication between physicians and other care givers is a leading cause of preventable medical errors.   It’s been estimated that communication mistakes during medical care account for about one-third of the medical mistakes that lead to 250,000 avoidable hospital patient deaths per year.

Threats from poor communication to hospital patients undergoing complicated care, like what is provided in hospital intensive care units, are only magnified.  New research exposes these dangers as well as provides steps to avoid poor communication in ICUs that seriously threaten patients.

The recently published study was conducted from October 2015 to May 2016 at eight intensive care units and included 3,240 patient handoffs.  The goal was to determine if patient safety was improved in the ICU when patient handoffs included a standard protocol to follow.

Standard Protocol for ICU Patient Handoffs

This protocol is known as IPASS, an acronym for the following components included in every proper patient handoff:

·         Illness severity

·         Patient summary

·         Action list

·         Situation awareness

·         Synthesis by receiver

These comprise the key information to be communicated by the outgoing treatment team and proper actions by the incoming team.  They apply to information given both verbally and in writing.

As part of the study, all medical care providers were trained on this protocol.  Cards were even printed with the IPASS acronym and made available to ICU staff to keep with them at all times.

The ICU patient handoffs following training and implementation, and their effect on patients, were compared to those prior to adoption. Medical professionals provided feedback on their experience. Quality of ICU patient care indicators – days on ventilators, for example – were measured.

Prior to implementing these structured patient handoff procedures, 10 percent of incoming medical care providers said they were unprepared following patient handoffs.  Poor coverage of patient medical histories and failure to adequately cover planned medical care contingency plans were among their top concerns.

Following implementation, researchers found the chances for dangerous patient handoffs in the ICU were reduced by 80 percent.  And an overwhelming majority of participating medical providers utilizing the IPASS guidelines felt they improved patient safety.  Researchers concluded that IPASS improved handoff communication and better prepared ICU physicians.

Poor communication during shift changes in the ICU is a known cause of dangerous medical errors.  As this study shows, there are also known proper steps to take in reducing medical errors and preventable patient deaths.

If you were catastrophically hurt or had a family member die during medical treatment, you may have been a victim of a substandard level of care.  Discuss your experience with a medical malpractice lawyer, who can investigate further.

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

Authored by Gray, Ritter & Graham, P.C., posted in Articles May 29, 2018