Risk Management:
"What we've got here is...
failure to communicate"
by James B. Couch, M.D., J.D., FACPE
Managing Partner & Chief Medical Officer
Patient Safety Solutions, LLC
(Dr. Couch is also the Patient Safety Risk Management Consultant for Princeton Insurance)
At the core of most medical errors
Despite all the latest emerging liability theories and causes of actions which are the subject of countless articles and seminar presentations among trial lawyer groups, the significant majority of medical errors still boil down to some kind of breakdown in communication between and among care providers. This conclusion evokes the memorable line from the movie Cool Hand Luke which is the title of this article of Risk Review.
Movie still from Cool Hand Luke
One of the most frequently cited studies corroborating this conclusion came out of the Robert Graham Center for Policy Studies in Family Practice and Primary Care in Washington, D.C.
For six months, primary care physicians used a secure Internet connection to file anonymous reports of practice errors. Only the harms and costs affecting patients were counted and classified. Three categories of harm were used: physical injuries (physical health complications from errors during the reporting period), errors that had no reported immediate effect but that heightened the patient’s risk for complications after the reporting period (such as poor control of hypertension), and psychological or emotional injuries (such as frustration or anger).
And the findings were…
Key findings corroborating the importance of miscommunication in medical errors included the following:
- A chain of errors was documented in 58 of the 75 reports. Of these, 33 incidents included at least two errors, 17 had three, and eight had four errors
- The most conspicuous finding was the frequency with which the final errors in the reported incidents were precipitated by errors in communication. Errors in communication set off 47 of the 75 (63% of the incidents reported by the physicians)
- Of the 64 errors in communication reported by the physicians (some incidents involved more than one error in communication), 57 were informational miscommunication that might have been prevented through the use of computers or other information systems. Woolf, SH, et .al., A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors; Annals of Family Medicine (July/August, 2004).