The Joint Commission estimates that 70 percent of sentinel events include communication breakdowns as one of the root causes of preventable patient injury. When we review our closed claims, we see, but for the communication failure, the patient injury would never have occurred. Also, national data studies reveal that 34 percent of OB cases, 26 percent of surgery cases, and 38 percent of general medicine cases involve one or more communication errors. We find similar results in our CAP claims reviews.
CAP’s ongoing, internal and external data review indicates that communications failures often occur at a critical point in the diagnostic process. These situations include:
- Missing incidental findings on a report
- Failure to note something relevant in the patient’s history
- Failure to communicate an important finding to the patient or family
There are many other types of communication failures that can result in a claim. These include:
- Incomplete handoff between providers, regarding the patient’s condition
- Poor documentation -- either inaccurate, incomplete, or illegible
- Inadequate informed consent
- Failure to respond to the patient’s concerns, calls, questions
- Inadequate patient education
- Failure to accommodate low health literacy or provide language assistance, and
- Failure of staff to advocate for your patient and to escalate safety concerns.
Some CAP closed claims examples of communication failures, resulting in patient injury include:
- A hospitalist notes pending labs in the patient’s discharge summary and assumes that the primary care physician will follow up. There is no other handoff communication between the physicians. It arrives five days after discharge and after the patient’s visit. The patient is unaware of the pending results. The abnormal result goes unaddressed.
- A cardiologist assumes the patient is familiar with the side effects of the newly prescribed anticoagulant medication and prescribes it without fully educating the patient. The patient takes both anticoagulants.
- A nurse documents a change in the patient’s condition assuming that the physician will read her note when he rounds. The changes noted go unaddressed in the patient’s medical record.
George Bernard Shaw once said, “The single biggest problem in communication is the illusion that it has taken place.” The best way to improve communication is to think like a patient safety engineer or a risk manager. Identify the types of critical information that you communicate, anticipate where it might break down, and implement systems to prevent communication failures. The most common ways to prevent communication breakdowns are to:
- Provide copies of labs, a summary of the visit, and the patient’s current medication list after each visit
- Request that copies of discharge summaries be sent to PCPs
- Establish missed appointment protocols
- Offer patient education materials
- Implement referral tracking systems
- Devise a follow-up process for labs and reports
- Standardize handoffs for critical information
- Institute a complaint management process
Communication is challenging because healthcare is challenging! There is an abundance of data and information that must be managed and understood. Only 12 percent of U.S. adults have the health literacy skills needed to manage their own healthcare in our complex healthcare system and, sadly, these individuals’ ability to absorb and use health information is also compromised by stress or illness.
Conveying the correct information, to the correct patient, that is timely and understood is the challenge facing all healthcare practitioners. To improve communication with patients:
- Make health literacy a core value in your practice for all staff
- Verify inpatient understanding using techniques such as Teach-Back
- Adopt universal health literacy precautions – at a minimum, use plain language with all patients
- Provide translation services
- Respond to patient complaints
Effective communication is not only critical to meeting patient needs and improving patient safety, it is also necessary to improve the patient experience and how we manage the delivery of healthcare to all patients. The ability to explain, listen, and empathize can profoundly impact relationships with patients and colleagues. For this reason, invest time to identify communication barriers and develop communication systems that will improve communication with patients and colleagues across the continuum of care.
With patient safety as the objective, CAP risk management specialists are available to assist you to identify patient communication failures and provide advice and guidance to establish systems to catch these failures to prevent patient injury and mitigate risk. Members may request a practice visit by calling 800-252-0555 or by emailing the Risk Management Department at riskmanagement@CAPphysicians.com.
Communication is a key component of the CAP Cares Program, an early intervention program that provides support and advice in the immediate aftermath of an adverse outcome. CAP Cares staff members are available to provide CAP members with information and communication techniques to safeguard their relationship with the patient and manage potential risks. The CAP Cares Hotline is available 24 hours a day, seven days a week, for adverse event/outcome management. We encourage you to call 1-800-252-0555 when a problem arises.
Ann Whitehead is Vice President, Risk Management and Patient Safety for CAP. Questions or comments related to this article should be directed to awhitehead@CAPphysicians.com.