Medical Malpractice from Communication Failures and Handoff Errors in a Healthcare Setting

The technical term for the problem of communication failures and handoff errors in the medical field is discontinuity. A doctor who is treating a patient will hand them off to the next doctor when their shift ends, the nurses who administer care also change shifts and they must successfully transfer clinical information to the next nurse who is rotating on shift. When critical information does not get communicated from the departing health care provider to the new one, it can lead to preventable medical errors, injuries and death.

According to the Patient Safety Primer, published by the Agency for Healthcare Research and Quality, the process for transferring the responsibility for the care of a patient from one healthcare provider to another is called a “handoff,” and “sign out” refers to the act of transmitting information about the patient. According to the Joint Commission on Accreditation of Healthcare Organizations, ineffective hand-off communication plays a role in approximately 80 percent of serious medical errors. Defective hand-off do not just contribute to causing patients harm, but they can also lead to delays in treatment resulting in increased length of stay in the hospital.

Communication failures in the healthcare setting can be linked to 1,744 deaths in five years according to a recent report, Malpractice Risks in Communication Failures. Nearly 2,000 patient deaths and $1.7 billion in malpractice costs could have been avoided if medical professionals communicated more clearly between themselves and their patients. The malpractice risk study revealed that communication failures were a factor in 30 percent of the malpractice cases analyzed for the study.

Analysis who contributed to the study worked with about one third of all paid medical malpractice claims in the U.S. from a representative sampling of hospitals and doctors. They looked at 23,658 cases between 2009 and 2013 and identified 7,000 cases where communication errors harmed patients.

What has been the impact of electronic medical records on communication among medical professionals?

The research study found that the purpose of making medical records electronic was to improve communications, in some cases they actually did the opposite. In some cases diagnoses were entered into a patient’s record, but not flagged by their doctor and in one tragic case a missing lab result caused the death of a patient. The results of miscommunication in preventable medical errors is much greater than this report indicates because they only looked at a sampling of paid malpractice claims. Only a small percentage of all malpractice cases are litigated or settled.

What is being done to eliminate hand-off errors and reduce miscommunication in the healthcare setting?

There is an emerging methodology called I-PASS, developed at Children’s Hospital in Boston in 2008, which is focused on improving communication through the use of a methodical approach to relaying patient information during hand-offs. In a study published in the New England Journal of Medicine, medical errors dropped by 23 percent when nine pediatric hospitals began following the I-PASS approach, which is an evidence-based, standardized approach to teaching, evaluating and improving hand-offs.