Did you know that communication breakdown between doctors, nurses and other care team members is one of the leading causes of unexpected death or serious personal injury? Communication errors, misinformation, or blatant lack of communication all contribute to medical errors, which could be treatment- or diagnosis-based.
Every instance of care requires timely, accurate communication between various members of a patient’s care team. However, communication breakdowns among care team members are ubiquitous. In today’s fragmented healthcare delivery system, care team members are scattered across facilities using different technologies. Not only that, there are cultural, hierarchical and resource barriers that impede communication between caregivers. All of these obstructions result in unsafe, uncoordinated patient care, which can lead to severe, and sometimes catastrophic, harm.
What Types Of Communication Breakdowns Cause Patient Harm?
Communication failure was directly linked to 30 percent of the medical malpractice cases reviewed in a recent study by CRICO Strategies. Forty-four percent of those cases resulted in high-severity patient injury; nearly 1,750 resulted in patient death. Over half of the cases reflected some type of communication failure among care team members. Those types of communication breakdowns included:
- Miscommunication Regarding The Patient’s Condition
Do physicians caring for the same patient, but at different facilities, communicate with each other? Do physicians actually listen to nurses and other care team members? Do nurses speak up when they see something amiss? Do care team members use outdated processes to communicate? Do providers properly inform other care team members during patient handoffs and transitions? The consequences of fragmented care, hierarchical culture, and cumbersome technologies are failed communication between care team members and impeded patient safety.
- Insufficient, Inaccurate, Delayed Or Illegible Documentation
Care team members are interrupted dozens of times per day, many times unnecessarily. This results in lack of time or focus to properly document patient vitals, clinical findings, medication notes, or other patient information, which directly contributes to patient harm.
- Failure To Read The Medical Record
That same lack of time and focus also results in failure to read or notice essential points in the medical record. Even if, for example, a nurse does properly document patient vitals, the physician may not take the time to read and understand the implications of a procedure or medication ordered.
What Happens When Care Teams Fail To Communicate?
The outcome of failed communication between care team members: dangerous, harmful practices that lead to patient injury and death.
Here are just a few actual illustrations of what can happen when physicians and other care team members are unable or unwilling to properly converse about patient care.
- Information About Patient Condition Not Shared During A Shift Change Causes Birth Complications
An expectant mother arrived early morning at Labor and Delivery, where she was seen by the obstetrician. During the morning shift, there was a disturbing change in patient vitals, which was not communicated to the incoming obstetrician during the mid-day shift change. Additionally, the patient’s nurse failed to communicate a sense of urgency to the incoming obstetrician. By the time the OB arrived to assess the mother, the infant was delivered, but with significant complications.
- Concerning Lab Results Missing From Consult Request Leads To Patient Death
A patient complaining of shortness of breath and chest congestion had a chest X-ray done by his family physician. The X-ray confirmed pneumonia, but also showed signs of early congestive heart failure; however, this concerning lab result was neither communicated to the patient, nor included in a subsequent pulmonology referral. The family doctor and pulmonologist did not communicate directly, and the pulmonologist only treated for pneumonia. The patient later ended up in the emergency room, where he died of heart failure.
- Failure To Document or Administer Orders Results In Patient Death
Test results from a patient who went to the emergency room confirmed a stroke had occurred a few days prior. Neurology admitted the patient and gave orders to the floor nurse to administer fluids and contact another physician on staff for assessment. Those orders were never documented or administered. The patient lost consciousness and died 10 days later.
What Can We Learn From Medical Malpractice Cases Involving Communication Breakdown?
Cases like these uncover systemic gaps in care delivery and missed opportunities for the care team to have clarified information to prevent disastrous outcomes. Even more concerning, many of the appalling events found in medical malpractice cases reflect instances when communication almost happened. The effort to transfer information was intended, or even initiated, but not completed.
When providers simply don’t document or ignore information vital to keeping a patient safe, we have a problem. This is their ultimate responsibility: first, do no harm. Unfortunately, we see cases every day where care providers have contributed to death or injury of a patient because they failed to communicate with their team members.
How To Take Legal Action If This Has Happened To Your Family
Do you believe a family member suffered or died because the care team did not communicate with each other as they should have? If so, you should first contact a medical malpractice attorney who can evaluate your case.
Ross Feller Casey is among the nation’s leading personal injury law firms and has an unmatched record of victories in all types of medical malpractice lawsuits.
Cases like these can often be difficult to prove because there is lack of documentation, and are often “he said, she said” situations with care providers pointing fingers at each other. You need a legal professional who will gather evidence to determine where and how the care team failed to provide safe care for your family member.
Medical malpractice cases involving failed communication between care team members often result in higher financial compensation than other types of cases. You could be eligible if your family member has been affected. For a free consultation, contact Ross Feller Casey now.