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Poor Transitions in Care May Lead to Serious Medical Errors

Medical treatment can be complex, involving many different healthcare providers and different facilities.  Poor transitions between providers or facilities can lead to serious medical errors, according to a new report on medical malpractice lawsuits.

When a patient is transferred to another provider’s care or facility it is known as a “transition in care.”  Another common term for this important stage is “patient handoff.”

Good communications during this time are vital.  If complete medical records and treatment plans are not forwarded or if there are misunderstandings between providers or facilities, medical errors and serious patient harm may occur.

Coverys, a provider of medical malpractice insurance, recently released a study of nearly 5,300 closed medical malpractice lawsuits between 2017 and 2019, noting that previous research found that 80% of medical errors are caused by problems during transitions in care.

Researchers found 210 of the lawsuits had ineffective medical care transitions that directly led to a serious medical error. Nearly half of those lawsuits – 45% – involved the death of the patient.

Miscommunications that Lead to Serious Diagnostic Mistakes

According to the study (“Care Transitions: Through the Lens of Malpractice Claims”), the leading medical error resulting from poor communications during patient handoffs was misdiagnosis.  This error was alleged in 42% of the medical malpractice claims.  The two top misdiagnosis errors alleged were:

·        Problems with test results – either sending or receiving

·        Problems with physician follow-up with patient

Coverys found the top four medical conditions involving the misdiagnosis claims were potentially life-threatening that often may require multiple healthcare providers:

·        Cancer

·        Cardiac/vascular

·        Infection

·        Neurological

Transitions in care can be intra-facility (moving patient from one hospital department to another), from one medical office to another, or from one facility to another.  More than 60% of the care transition issues involved external transitions – the patient being transferred to a different facility.

Internal care transitions – between a hospital’s emergency department and radiology department, for example – accounted for 25% of the transition care lawsuits, and the remaining 14% occurred in an office-to-office transition.

Poor Decision-Making During Medical Care Transitions

Nearly one out of three errors occurred during clinical decision-making. These errors included:

·        Failure to take into account a patient’s individual or family medical history

·        Negligent monitoring and/or treatment following surgery

·        Failure to obtain a consult or referral

·        Inappropriate or inadequate medical tests

·        Narrow diagnostic focus

The study offers several recommendations for improving transitions in care and reducing medical errors from poor patient handoffs. One is to focus on better communications between physicians and patients, and among healthcare providers. Verification that medical instructions are properly understood should be confirmed in writing.

Another is the use of standardized patient handoff checklists to improve patient safety and medical outcomes. Also, when different medical providers and facilities are involved, consistent follow-up and a shared accountability for the patient’s well-being are imperative.

When a patient dies unexpectedly a medical error may be involved.  If the care involves multiple physicians and/or multiple facilities, those who made the error may not be forthright and take responsibility.

If you believe substandard medical care was responsible for the death of a loved one, consult an experienced personal injury lawyer.

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 October 5, 2021