Study: Poor Communication Leads to Malpractice, Death

Patient Safety Monitor Insider

February 3, 2016

Poor communication in healthcare has tangible, measurable effects. A new study released by CRICO Strategies found that communications failures were a factor in 30% of malpractice cases between 2009 to 2013, including 1,744 deaths. The reports estimate that both the deaths and $1.7 billion in malpractice costs could have been avoided with better communication between patients and physicians.

Several of the cases studied involved simple errors that turned fatal. One case involved a nurse failing to tell a physician that a postoperative patient was showing internal hemorrhaging symptoms. Another involved a heart condition not being properly flagged in an electronic report before being sent to a lung doctor. The patient died in both cases.

Researchers said that factors hindering effective workplace communication included such as interruptions, clunky electronic records systems, overworked personnel, and a hierarchical workplace culture. The report does talk about a possible solution in the form of the I-PASS program. I-PASS was developed at Boston Children’s Hospital and is a mnemonic device standing for:

  • Illness severity
  • Patient summary
  • Action list
  • Situation awareness and contingency planning
  • Synthesis by receiver

The I-PASS system has been adopted by 32 hospitals, teaching staff to run through the mnemonic when relaying information about a patient. A recent report published in The New England Journal of Medicine found that using I-PASS helped reduce medical error rates by 23%. 

To learn more about I-PASS, click here.