By Stacey Kusterbeck
Most ED patients are, at some point, handed off to other providers — admitting physicians, the ICU team, on-call consultants, or primary care physicians. Good communication is crucial in the ED, “more so than in most settings,” according to Chris Landrigan, MD, MPH, chief of general pediatrics at Boston Children’s Hospital. “The ED doctor takes an initial sense of what’s going on and, in every case, has to convey that to someone else. It’s just so core to what they do that thinking about miscommunication for ED docs is particularly important.”
Landrigan and colleagues set out to learn the proportion of malpractice claims that involved a communication failure and the nature of those claims.1 “We wanted to better understand how frequently, and in what way, communication impacts medical malpractice,” says Kate E. Humphrey, MD, MPH, CPPS, a pediatric hospitalist at Boston Children’s Hospital and associate medical director of patient safety and quality.
Researchers analyzed 498 malpractice claims that were filed from 2001-2011 in the CRICO Strategies Comparative Benchmarking System. They searched for claims that involved a communication failure and failure type. About 10% of the claims involved the ED. “We knew that in studies looking at adverse events in hospitals in general, miscommunications are responsible for something like 50% to 80% of the most serious medical errors that happen in hospitals,” Landrigan says. “Typically, cases are multifactorial. But communication is this thing that kind of goes awry in almost all serious cases reported.”
However, in the malpractice literature, it was unclear what role communication was playing because claims usually are analyzed based on setting and clinical subtype of errors, rather than root causes. “We wanted to see if in the malpractice world, the same things held true that we were seeing in the patient safety world generally,” Landrigan explains.
Miscommunication was responsible for 49% of malpractice cases. “This is largely in line with the broader literature in patient safety, but it hadn’t emerged from the malpractice literature. It was great to harmonize that, and to harmonize ways of looking at malpractice,” Landrigan says.
Contingency plans, diagnosis, and illness severity were the information types miscommunicated most often. If there was a communication error, researchers examined who it involved. In ED claims, “a lot of times, the communication error was between the providers and the families, as opposed to the medical team itself,” says Melissa Sundberg, MD, MPH, another study author and a pediatric emergency physician (EP) at Boston Children’s Hospital.
Of claims with communication failures, failed handoffs were involved 40% of the time. For ED claims with handoff errors, the problem was providers did not know the next step if the patient’s condition declined. “Contingency plans are not always communicated well,” Sundberg notes.
As a hospitalist, Landrigan has observed poor communication when ED patients are handed off. In some cases, the EP obtained a neurology consult for a patient with a ventricular peritoneal shunt. The neurologist indicated it probably was OK for the patient to go to general service because the problem did not seem like a shunt failure. Those cases did not always go as expected. “If things start to deteriorate, you need to get neurosurgery involved very quickly,” Landrigan says.
It is critical the team on the floor is attuned to the EP’s thought process on what to do if things do not go as planned. “In digging through the claims on the types of communication failures that contributed to malpractice claims most often, it was exactly that type of thing,” Landrigan observes.
In some cases, providers were quite worried about a patient, but that did not come across to whoever treated the patient next. “In those cases, there may be a delay in escalating care or taking action because the team up on the floor or ICU is not adequately keyed up on just how sick this patient is and what our worries are,” Landrigan says.
Securing buy-in from hospital administrators to make investments to improve patient safety, including handoff communication in the ED, can be challenging. Compelling anecdotes about cases when things went terribly wrong can grab leaders’ attention. “But you also need hard data to make a financial business case,” Humphrey argues. “Having numbers behind us to show the financial burden of medical malpractice can help us speak to different leaders in the organization to further that work.”
Malpractice claims that included communication failures were less likely to be dropped, denied, or dismissed than claims that did not involve communication failures (54% vs. 67%) and were more expensive to defend. Mean total costs for cases involving communication failures were higher ($237,000 vs. $154,000).
Investigators studied how many malpractice claims could have been mitigated with a properly used handoff tool. “We found that a structured handoff tool can be very helpful to make sure the appropriate information is transferred,” Humphrey reports.
In looking at the subgroup of handoff-related claims, researchers found 77% of those cases could have been averted if clinicians had used a handoff tool. “We found there is a lot of potential there,” Landrigan says.
As co-founder of the I-PASS Patient Safety Institute, Landrigan’s work has focused on how to hand off in an evidence-based way. One problem is handoffs have been handled inconsistently and haphazardly in EDs. “It was really idiosyncratic and based on individual physicians. A lot of times, handoffs weren’t happening at all,” Landrigan says.
During his own training, Landrigan often heard providers making comments such as, “You don’t have to tell me anything. If something goes wrong, I’ll figure it out.”
“There is a growing recognition of the notion of the importance of making people attuned to the things you’re worried about,” Landrigan notes.
Although small communication problems arise all the time with ED handoffs, major adverse outcomes that result in litigation rarely happen. Thus, individual EPs do not take it as seriously as they should. “We need to shift that thinking,” Landrigan asserts.
Many EPs view handoffs as a task they have to handle without the appropriate sense of urgency. “There’s a failure to recognize that doing a handoff in those few minutes at the end of a shift is probably the most dangerous thing you’re going to do all day,” Landrigan says. “Getting it right is really critically important.”
For EDs, the implementation of handoff tools can lower the likelihood of errors. “It’s not a huge leap to say that if you are decreasing injurious errors, you are probably avoiding malpractice claims,” Landrigan says. “Connecting the dots is not terribly difficult.”
REFERENCE
- Humphrey KE, Sundberg M, Milliren CE, et al. Frequency and nature of communication and handoff failures in medical malpractice claims. J Patient Saf 2022;18:130-137.
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