Lack of Communication Causes Serious Injuries

By Mitchel L. Zoler 

CHICAGO -- Faulty transmission of patient information between attending surgeons, and between surgical residents and attendings, was cited as the most common type of communication breakdown that led to medical errors and serious patient injuries in a recent review of 444 malpractice cases.

Potential interventions to prevent such events include clinically oriented triggers that mandate communication with attending surgeons, standardized handoffs and transfer protocols, and read-backs of one-on-one communications, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

Although it is true that communication breakdowns have been known for some time to contribute to adverse events in medicine, they are "rarely considered in the process of risk adjustment," commented Dr. Carlos A. Pellegrini, who is a professor and chairman of surgery at the University of Washington in Seattle.

"It's sad to see that, in this area, we lag far behind other disciplines," such as commercial aviation, he said.

Dr. Greenberg and her associates examined malpractice case records collected from four insurance companies through the Malpractice Insurers' Medical Error Prevention Study to determine the role and nature of communication breakdowns.

Of the 444 cases available in the study, 258 involved a serious injury to a surgical patient caused by a medical error. Sixty of these cases were found to have been attributable to a communication breakdown and were the focus of the new analysis.

Forty-three cases involved a single episode of a communication breakdown; the other 17 involved two or more episodes. In 37 cases, a trainee was involved.

About two-thirds of the communication failures occurred during elective surgery; 10 episodes occurred during emergency procedures. The episodes were uniformly distributed among the preoperative, intraoperative, and postoperative periods.

Errors in verbal communication were involved 85% of the time. In 49% of the episodes, information was never transmitted, and 44% of the errors involved inaccurate information transmission.

Handoffs in patient responsibility resulted in errors 43% of the time, and transfers in the location of patients in 39% of the episodes. Ambiguity about the responsibilities of the medical staff occurred in 58% of the communicationsbreakdowns.

The two most common breakdowns occurred between two attending surgeons--in nine episodes--and between a resident and an attending--also in nine episodes--reported Dr. Greenberg, a surgeon in the Center for Surgery and Public Health Policy at Brigham and Women's Hospital in Boston.

Eight of the nine attending-to-attending breakdowns involved handoffs and seven episodes also involved ambiguous responsibility and coverage. Dr. Greenberg and her associates recommended using a standardized handoff protocol between attending surgeons.

VERBAL COMMUNICATION ERRORS WERE INVOLVED IN 85% OF BREAKDOWN CASES. IN 49%, INFORMATION WAS NEVER TRANSMITTED, AND 44% INVOLVED INACCURATE INFORMATION. TRANSMISSION.

The nine breakdowns between residents and attendings involved ambiguous responsibilities and failure to transmit information on patient status. The researchers suggested using clinical triggers that mandate communication between residents and attending surgeons.

Such triggers would include changes in the patient's location or the onset of serious events, such as cardiac or pulmonary arrest or the need for an unplanned blood transfusion.

They also recommended the use of read-backs to ensure that physicians exchange accurate information. When Dr. Greenberg and her associates reviewed all of the episodes, they estimated that triggers could have mitigated or prevented 41%-68% of them, and that handoff and transfer protocols could have mitigated or prevented 18%-54%.

By reviewing medical malpractice cases that went to litigation, the researchers hoped to "catch the more severe patterns of communication breakdowns," Dr. Greenberg said.

Her next step is to conduct an observational field study to identify the types of breakdowns that occur in everyday practice.