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Guest Commentators:

  • Chris Landrigan, MD, MPH
  • Nathan Mick, MD
  • Mark E. Reynolds
  • Meg Rosenblatt, MD
  • Gretchen Ruoff, MPH, CPHRM
  • Dana Siegal, RN, CPHRM, CPPS

Nearly 3 in 10 medical malpractice cases have identifiable problems with communication, according to a report by CRICO, the malpractice insurer for the Harvard medical institutions. In its latest analysis of 23,000 malpractice claims across the United States released in late 2015, CRICO found that 30 percent involved at least one specific communication breakdown. The report highlights general medicine, OB, nursing, and surgery.

The study authors point out that the communication problems are not limited to a provider’s people skills or a patient’s language barrier. The benchmarking report shows that harm resulted when facts, figures, or findings got lost between the people who had the information and the people who needed it.

In follow-up to the report, the CRICO Strategies division held a day-long conference in June [2016] in Boston with patient safety leaders from across the country. Mark Reynolds is President of CRICO. He explained the importance to patients and providers of understanding these communication flaws—and exploring solutions.

“Cases that are identified as having a communication error are twice as likely to result in a payment than other cases that don’t have a provider-to-provider communication errors. Twice as likely. In my world that is a remarkable finding. Almost nothing is twice as likely to happen than something else.”

According to CRICO Strategies Director of Patient Safety Dana Siegal, provider-to-provider communication, which accounts for 40 percent of these errors, may be the most worrisome. Siegal notes that these problems with sharing critical information can be deadly.

“Communication gaps are very real. They cause patient harm. They cause patient death. They cause provider burnout. They cause patient dissatisfaction, and we are empowered to make a difference. We need to engage and we need to move forward. We need to be persistent because this is what we live in.”

Efforts, of course, to fix communication errors, are underway across the health care industry. The report found that 27 percent of the 7,149 malpractice cases in the study group involved surgery. Sliced further, the data show that more than a quarter of all surgery malpractice cases involved one or more communication error. About two-thirds of those were provider-to-patient failures, overlapping with 48 percent that included provider-to-provider errors. These included factors such as a surgeon failing to communicate abnormal findings in pre-op EKGs to the anesthesiologist, or a failure to document an intra-operative drop in impulse levels to a covering post-op surgeon, resulting in delayed diagnosis of nerve damage.

One of the conference speakers was Dr. Meg Rosenblatt of Mt. Sinai St. Luke’s Hospital. Dr. Rosenblatt, an anesthesiologist, described a multi-hospital system effort to make pre-operative patient evaluations better—and better communicated to key providers before surgery begins. She says their analysis showed that pre-op medical examinations could be too fractured and incomplete.

“Anesthesiologists as a group, I look at a patient and say, 'Can we intubate them?' We listen to their lungs, we listen to their heart, and that’s for the most part what we do. The surgeon writes, 'cholecystitis: cholecystectomy.' And that’s the surgical note. So we were looking to develop a comprehensive medical exam; a written document that was a full examination of the patient. It was to begin a conversation among physicians, and you'll see how we created that. The goal was not only to decrease cancelations—to bring our patients as good as they could be to the operating room—but it was also to begin a dialogue between physicians and the hospital.

The project also included Montefiore Medical Center and several other systems covered by the same malpractice insurance and risk management program—FOJP. According to Dr. Rosenblatt, a new, mandatory, pre-operative medical exam form and training, backed up by policy enforcement, led to a decrease in patients being waved forward to surgery without a comprehensive, documented, pre-operative evaluation. The sharing of malpractice data analysis that shows the connection between the absence of a documented exam and negative consequences helps fortify the front-line people who have to enforce the presence of a medical examination form before surgery can begin.

Another key category for communication errors is the management of test results. Gretchen Ruoff is a Senior Program Director for Patient Safety at CRICO Strategies. Ruoff pointed out that a previous benchmark report focusing on diagnosis showed the seriousness of effective routing of test results.

“In order to arrive at the right differential, arrive at the right tests, to call in the right consults, and send the patient off with the right plan of care, that’s not just all up here. It’s making sure that the right information has come to the provider at the right time, in the right place, so that they’re well-informed to move along that trajectory.”

This analysis has spurred a team-training effort across institutions within the Harvard system that focuses on communication among providers in every-day interactions.

A test-result intervention involving emergency departments at Maine Medical Center and nearby facilities was described by Dr. Nathan Mick. Dr. Mick is the Director of Clinical Operations, Pediatric Emergency Medicine. Well-known problems across the country with test results ordered in the ED—but received after patient discharge—led to his hospital system taking charge of managing test result follow-through for discharged patients.

“We felt we had a responsibility for these tests that came out of the emergency department. The cholesterol that’s ordered by the cardiologist, the bone density study that’s ordered by the orthopedist: to have all that flow to a primary care’s office on their 2000-patient panel really didn’t seem like the safest thing for patients. It seemed like it would overwhelm them.”

Instead, the ED assigned a nurse practitioner to review these test results, and ensure proper follow-through. The office practices associated with these patients and Maine Medical Center also assigned a staffer to review incoming test results and follow up. Aided by the newly-installed electronic medical record capabilities, Maine was able to ensure that results were reviewed and acted upon, whether it is by the ED or the community provider.

A third project described at the conference involved patient hand-offs from provider to provider, and the communication that must take place. Boston Children’s Hospital now uses a standardized verbal hand-off protocol called I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver).

Dr. Christopher Landrigan heads the project, which has evolved from a pilot study to a multi-institutional/multi-regional intervention. Dr. Landrigan is Research Director of Inpatient Pediatrics at Boston Children’s. He said that the initial pilot demonstrated that information exchanged during hand-offs is nowhere near as standardized as history-taking notes for example.

“If you think for a moment just about how we were all trained in medical school, in the taking of a history. It doesn’t matter if you’re a surgeon or you’re a pediatrician or internist in Singapore or the United States. Pretty much everybody does a chief complaint, does their history of present illness, past medical history, past surgical history, and so on and so forth. And there's this really standardized formal structure that if you are reading through a note, you expect to see the information in a certain order and that helps you to form a mental model of what’s happening with the patient. But for some reason, that process never translated over to hand-offs. There is really no standard or structure whatsoever, so that the amount of information that was being passed at change of shift was tremendously variable. And, without any type of a structure to what that looks like, it’s really hard sometimes to keep track of what bits of information should go where.”

According to Dr. Landrigan, the structured I-PASS hand-off protocol led to wide improvements. Providers got the information they needed more often, more consistently. And error rates and harm to patients connected to hand-offs went down by as much as 20 percent.

CRICO Strategies’ Dana Siegal reminded the audience that reducing communication errors that hurt patients will require a long-term effort, determination, and action.

“Folks, these are not policy changes that go up on the back of the restroom door. These are not a new metric of the month—and I see the smiles because all of us quality and risk managers know that sometimes that’s what it feels like. These are real, cultural, behavioral ways we deliver health care changes, and they are meaningful and critical, but they do not happen overnight.”

CRICO’s comparative benchmarking report, “Malpractice Risks in Communication Failures,” can be ordered online free of charge at https://www.candello.com/Insights/Candello-Reports

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MedMal Insider

Real Malpractice Cases from the Harvard Medical Community.
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About the series

Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.


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