EXECUTIVE SUMMARY
The quality of patient handoffs directly affects malpractice claims. A standardized handoff system can significantly improve patient safety.
- A large proportion of communication-related claims involved handoffs.
- Handoffs often involve failure to adequately communicate the severity of illness.
- Contingency plans also often omitted or conveyed inadequately.
Patient handoffs affect safety, although it is possible malpractice risk is a downstream effect. A large study of malpractice claims revealed a direct relationship between the quality of patient handoffs and claims.
Researchers at Boston Children’s Hospital reviewed 498 medical malpractice claims, selected at random from Candello, CRICO’s national medical malpractice collaborative. Of the cases that involved communication failures, 40% included a handoff of care.
Of those cases involving patient handoffs, 77% likely were preventable with a handoff tool developed by the I-PASS Patient Safety Institute. Additionally, malpractice cases involving communication errors were more expensive to defend, with a cumulative payout of $58 million vs. $39.1 million for cases in which communication errors were not a factor. (An abstract of the study is available here. Another earlier study showing the effectiveness of improved handoffs can be found here.)
The I-PASS handoff program has been associated with improving patient safety by reducing miscommunications, medical errors, and injuries due to medical errors. The program uses a uniform structure for verbal and written communication, based on the I-PASS mnemonic: illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. (More information on I-PASS is available here.)
Research Establishes Direct Link
The cases resulting in malpractice claims are only a small subset of all cases involving harm related to a patient handoff, so the effect of improving handoffs likely is greater even than what the research revealed, says Kate E. Humphrey, MD, MPH, a pediatric hospitalist at Boston Children’s Hospital and the lead author of the study.
The tie between communication failures and malpractice claims has been established previously, but this research draws a direct link between a particular form of communication failures — patient handoffs — and malpractice claims, says Christopher P. Landrigan, MD, MPH, co-founder of the I-PASS Patient Safety Institute and chief of general pediatrics at Boston Children’s Hospital.
“This study has built on previous research to clarify that link to claims, and, importantly, it also identifies some strategies and approaches that might mitigate or avert them,” Landrigan says.
Another important facet is that researchers studied not only the communication failures among critical care providers, but also between providers and patients and families.
“We saw a significant impact on patients and families in those gaps in critical, key pieces of information that can mitigate that risk,” Humphrey says.
The communication failures at handoff fell into several categories, explains Melissa Sundberg, MD, MPH, co-author and emergency medicine physician at Boston Children’s Hospital.
“Most of the failures involved information that was not passed on appropriately, but we further looked into whether it was related to a medication, radiology, lab study, or other information that was not passed on,” Sundberg says. “They covered a broad range of specific types of information, but most of them involved an omission of some type when communicating with other providers or the patient and family.”
Severity of Illness Often Missed
Humphrey notes a common omission was the severity of the patient’s illness along with contingency planning, which could be important for a family member caring for the patient at home. Another omission was the actual diagnosis.
The team explored potential interventions that may have averted some of the claims in the study, particularly whether the I-PASS system would have helped.
“For the large majority of handoff-related errors that we found, it was judged that it most likely would have averted the claim or mitigated it,” Landrigan says. He notes I-PASS focuses on two common omissions in the cases studied — severity of illness and contingency plans.
“That is by design because even a decade ago, when we were building I-PASS, it was clear in the literature that those were two elements we should focus on,” Landrigan says. “It is particularly interesting to see in this malpractice data set that those were two elements that fell down most often as patient information was being passed off.”
Sundberg says the research further confirms healthcare organizations should use some type of formal communication in patient handoffs.
“It is important to consider whether you have a structured way to communicate information not only between providers, but also to families,” Sundberg says. “Consider a way to have structure throughout the organization so that you might ensure some of these situations don’t lead to adverse events and near-misses.”
The direct link between patient handoffs and malpractice claims might prove useful to risk managers when seeking support from administration and clinicians for improvement programs.
“The risk management community has an incredibly important role in driving patient safety improvements across hospitals. Because of the high cost of malpractice claims, there a lot of resources in that system that can be turned toward potentially preventing these adverse events,” Landrigan says. “When studies like this come out that identify discrete sources of harm as well as potential strategies to avert them, it would be great if risk management could partner with the clinical sector to drive those strategies forward.”
SOURCES
- Kate E. Humphrey, MD, MPH, Boston Children’s Hospital. Email: [email protected].
- Christopher P. Landrigan, MD, MPH, Co-Founder, I-PASS Patient Safety Institute, Chief of General Pediatrics, Boston Children’s Hospital. Email: [email protected].
- Melissa Sundberg, MD, MPH, Emergency Medicine, Boston Children’s Hospital Email: [email protected].
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