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Mind the Gaps: Learning How to Avoid Miscommunication Pitfalls

by Lisa Heard, MSN, RN, CGRN, CPHQ and Gretchen Ruoff, MHP, CPHRM | June 14, 2016

Stories of patient harm resulting from a gap in communication were the inspiration for the 10th Annual CRICO Patient Safety Symposium, Mind the Gaps: Avoiding the Risks of Communication Failures in Patient Care, held at the Revere Hotel in Boston on June 9th (#CRICO16).

Case Dramatization

Supported by medical professional liability (MPL) data mined from CRICO Strategies' national Comparative Benchmarking System (CBS) of over 350,000 MPL claims from across the country, the day-long educational activity brought together local and national patient safety experts and clinicians to discuss critical “gaps” in communication with patients and among clinicians that lead to patient harm—and real-life strategies to address them. The touching real-life story of Rosie, a patient who died due to a delayed diagnosis of lung cancer, was told through the eyes of actors portraying Rosie’s daughter, office nurse, primary care physician (PCP), radiologist and emergency medicine physician.  This dramatization brought to light the sad truth of how a missed communication with patients and providers can lead to grave consequences. The day’s educational offerings focused on what we have learned from these stories of gaps in communication and the work that is being done to fill them.

Launching the day’s activity was a discussion about inpatient transitions of care.  The Joint Commission on Accreditation of Healthcare Organizations “estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.” Dr. Christopher Landrigan from Boston Children’s Hospital spoke to the audience about the work done by researchers to improve patient safety across care transitions by standardizing provider communication, with a specific focus on improving transitions of care. The I-PASS mnemonic stands for Illness severity, Patient condition, Action plan, Situational awareness, Synthesis of the receiver. The I-PASS Study was a landmark multi-site research communication and patient safety study involving nine institutions in the US and Canada.  This study revealed a 30% reduction in preventable adverse events after implementation of a bundle of interventions to improve resident physician communication during handoffs of patient care (called the I-PASS Handoff Bundle).

Drs. Shamamian, Rosenblatt, and BrodmanIn addition, members of CRICO Strategies’ extended CBS Community served as faculty to provide national perspective on critical communication risks in Surgery and in Test Result Management. Drs. Michael Brodman, Meg A. Rosenblatt and Peter Shamamian from New York hospitals Mount Sinai, St. Luke’s at Mount Sinai and Montefiore Medical Center respectively, gave engaging presentations on managing patient and provider expectations in the surgical preoperative and consent process, and the benefits of a multi-hospital collaborative approach to addressing communication gaps across the perioperative spectrum. Initiating best practices for the development of team training to improve communication and team work, Dr. Brodman described how he and his team transferred this important work in obstetrics to their hospital’s surgical specialties.  Dr. Rosenblatt explained her facility’s work on standardization of the surgical patient’s preoperative medical assessment. They concluded their presentation with Dr. Shamamian and his team’s work done to develop specialized surgical consents for high risk patient populations.

Nathan Mick MDDr. Nathan Mick from Maine Medical Center (MMC)—a member of CRICO’s national CBS data-sharing community—spoke to the referral management gaps in the emergency medicine arena.  Dr. Mick, an emergency department (ED) physician worked with his team at MMC to develop a system to follow up with patients on test results obtained in the emergency room.  This system involved institutional stakeholders and resulted in a monitored daily queue using an advanced practice nurse with prescribing rights to follow up directly with patients.  Finally, the system provided role clarity for the ED and PCP by stating ED physicians would be responsible for ED orders.

Dr. Helen Reiss - EmpathyThe presentations concluded with Dr. Helen Riess from Massachusetts General Hospital who spoke about the use of empathy as a communication skill. Dr. Riess described the neuroscience behind empathetic behavior as well some key tools providers can use to display empathy to the their patients and colleagues.  She also discussed the correlation between low empathy and provider burnout providing tangible methods to promote empathetic habits.

Siegal - Mind the GapsDana Siegal, RN, CPHRM, CPPS, Director of Patient Safety at CRICO Strategies, ended the day by summarizing the lessons learned through the day’s activity and finally closing with the hope of a time when communication failures are a thing of the past and people and systems will prevent another story like Rosie’s.

The event was attended by over 165 providers, staff, clinical and executive leaders, as well as leaders from captive and commercial MPL insurers from across the country, with positive feedback from CRICO-insured and CBS members for another successful symposium on the books!

For a different summary of the event, take a few moments to review CRICO Strategies Storify or search Twitter for #CRICO16.   

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  • Jennifer Rossi:
    June 17, 2016

    This was outstanding. I look forward to next year.

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