Monday, February 22, 2016

Failure to communicate

"What we've got here is failure to communicate," the Captain, a prison warden, famously said to
his stubborn prisoner in the 1967 film classic Cool Hand Luke. It's far from a friendly pronouncement, of course. But too often, communication channels really do break down, and the results in the medical arena can be especially dire, even catastrophic. That's the underlying message of a new report by CRICO Strategies, a Harvard-affiliated group of evidenced-based risk-management companies. "When information falls through the cracks, diagnoses are confounded, procedures are complicated, and subsequent care is compromised," says Heather Riah, CRICO's assistant vice president.

To probe the problem of communication failure, researchers looked at 23,658 medical malpractice cases filed between 2009 and 2013. (The CRICO database, which reflects the medical liability experience of more than 400 US hospitals and 165,000 physicians, contains 350,000 cases overall.)

Of the cases examined, communication failures of one kind or another contributed to patient harm in about 30%, or 7149, of the cases. Most failures occurred in surgery (27%), followed by general medicine (13%), nursing (9%), and obstetrics (5%). The inpatient setting—including the emergency department—accounted for 52% of the communication breakdowns, while ambulatory and other settings accounted for the remaining 48%. Researchers also found that 37% of all high-severity injury cases—including wrongful death cases—involved a communication failure.

Communication breakdowns were almost evenly split between clinician to clinician and clinician to patient, with some overlap between the two categories. On the clinician-to-clinician side, the most common breakdown involved a miscommunication regarding a patient's condition (26%), followed by poor documentation (12%) and failure to read the medical record (7%). On the clinician-to-patient side, breakdowns included inadequate informed consent (13%), unsympathetic responses to patient complaints (11%), and inadequate medication instructions (5%).

The report found that cases triggered by clinician-to-clinician communication failures were more likely to result in a payout than those centered on clinician-to-patient communications (49% versus 35%). The average payouts in cases involving communication lapses between clinicians were also higher: $484,000 versus $381,000.

What can be done to address these breakdowns? Researchers propose a greater emphasis on empathy—thereby increasing the odds that information is not only conveyed but received and well understood—and a more effective consent process, which is especially critical prior to surgery.

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