General Introduction/Overview

Communication issues underlie many patient safety problems, and communication breakdowns are contributing factors in most malpractice suits. The following claim abstracts provide examples of communication breakdowns with respect to critical test results that can affect patient safety and result in liability claims for healthcare providers and/or organizations.

Healthcare risk management and patient safety literature contain numerous accounts of medical errors caused by communication failures and a high proportion of liability claims and malpractice lawsuits have been attributed, at least in part, to communication-related issues.  Additionally, ineffective communication was the most frequently cited root cause of sentinel events reported to the Joint Commission between 1995 and 2004.   

Common risk factors in these types of claims include:

• Failure or delay in ordering tests
• Failure or delay in detecting incorrect test results
• Failure or delay in reviewing test results
• Failure or delay in acting upon abnormal test results
• Failure to inform (provider, patient, primary care or attending physician) of existence of test results

And a trend that has recently resulted in some large claims:

• Failure to ensure that the patient has actually had the tests done that were ordered.

The above listed communication errors can happen in laboratory, radiology, and other diagnostic tests in inpatient, emergency and ambulatory settings.

Ordering tests, reporting results, reviewing results and acting on them are all steps in a complex medical care process.  This process must be recorded in the medical record, both for quality of care needs and to provide a defense in the event of a claim.

In this issue of Risk Review, we conclude our three part series on this topic and review strategies for improving communication, with focus on reporting and acting upon critical lab test results, and action recommendations to improve communication among healthcare providers and between providers and patients.