(Mis)communication And Deadly Medical Errors
One area where communication failures and breakdowns too frequently put lives at risk is found in the issue of medical errors in providing health care.
Per research published in the Journal of Health Care Finance (Andel, Davidow, Hollande, and Moreno, 2012[i]) approximately 200,000 Americans die from preventable medical errors including facility-acquired conditions and millions may experience health care provider errors. Medical errors in the United States have an annual impact of roughly $20 billion. Most of these costs are directly associated with additional medical cost, including: ancillary services, prescription drug services and inpatient and outpatient care. Citing previous research (by the Society for Actuaries and conducted by Milliman in 2010) additional costs were attributed to increased mortality rates with about $1.1 billion or more than 10 million days of lost productivity from missed work based on short-term disability claims.
The published research estimated that the economic impact may be much higher when indirect costs are quantified, perhaps another $1 trillion annually when quality-adjusted life years (QALYs) are applied to those that die. Andel et. al, using the Institute of Medicine’s (IOM) estimate of 98,000 deaths due to preventable medical errors annually in its 1998 report, To Err Is Human, and an average of ten lost years of life at $75,000 to $100,000 per year, conservatively projected a loss of $73.5 billion to $98 billion in QALYs for those resulting deaths. Some research suggests that preventable health care error death costs may be up to ten times the IOM estimate.
Quality care and patient safety depends on multiple factors, all of which must be working harmoniously to ensure delivery. However, one key factor is the quality of communication at various critical points in the health care provider sequence. According to the University of Minnesota’ TAGS[ii] site “ Upwards of 100,000 deaths occur in the United States each year because of medical mistakes. One of the biggest factors contributing to the problem is miscommunication or lack of communication between multiple health care professionals.”
The Joint Commission Center for Transforming Healthcare[iii] reports that “ineffective hand-off communication is recognized as a critical patient safety problem in health care; in fact, an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. The hand-off process involves “senders,” those caregivers transmitting patient information and transitioning the care of a patient to the next clinician, and “receivers,” those caregivers who accept the patient information and care of that patient. In addition to causing patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.”
Marie McCullough’s writing in The Philadelphia Inquirer[iv] describes a horrific problem of problematic labeling and miscommunication leading to fatal errors in the administration of chemotrophic drugs. She begins the writing with a personal narrative about a patient who died due to a recurring medical error. Christopher Wibeto was receiving vincristine to treat cancer. Vincristine is a chemotherapy medication commonly used to treat several types of cancer. As McCullough describes, shortly after health care providers had injected the drug into Wibeto’s spine, doctors realized that a catastrophic medical error had occurred. Since vincristine is neurotoxic it must be diluted and given intravenously – it should never be injected directly into spinal fluid (which flows around the brain). As a result, Wibeto developed dementia, paralysis and died within days as a result of the improper administration of the drug. McCullough writes that “no one knows how many vincristine disasters have occurred. The Institute for Safe Medical Practices in Horsham has documented 125 fatal misadministrations since the 1960s, but experts believe that the real number is many times higher.” This type of medical error is preventable. Simple changes in the dispending containers, more effective warnings and successful health communication about procedures and verification processes are obviously warranted. Stories of medical errors such as the Wibetor case simply should never happen.
Most Common Root Causes of Medical Errors
The U.S. Department of Health and Human Services Agency for Healthcare Research and Quality[v] identified a diverse group of factors that cause medical errors. At the top of the list were the factors of communication, information flow, coordination and communication training/planning. Here are the top eight identified factors in rank order:
- Communication problems represent the most common cause of medical errors noted by the error reporting evaluation grantees. Communication problems can cause many different types of medical errors and can involve all members of a health care team. Communication failures (verbal or written) can take many forms, including miscommunication within an office practice as well as miscommunication between different components of the health care system or health care providers working different shifts. These problems can occur between health care providers such as primary care physicians and emergency room personnel, attending physicians and ancillary services, and nursing homes and patient services in hospitals. Communication problems can result in poorly documented or lost information on laboratory results, diagnostic testing, or medication information, and can occur at any point along the communication chain. Communication problems can also occur within a health care team in one location, between providers at different locations, between health care teams and other non-clinician providers (such as labs or imaging centers), and between health care providers and patients.
- Inadequate information flow can include problems that prevent:
- The availability of critical information when needed to influence prescribing decisions.
- Timely and reliable communication of critical test results.
- Coordination of medication orders at points of interface or transfer of care.
- Information flow is critical between service areas as well as within service areas in health care. Often, necessary information does not follow the patient when he or she is transferred to another service or is discharged from one component or organization to another.
- Human problems relate to how standards of care, policies, or procedures are followed. Problems that may occur include failures in following policies, guidelines, protocols, and processes. Such failures also include sub-optimal documentation and poor labeling of specimens. There are also knowledge-based errors where individuals do not have adequate knowledge to provide the care that is required for any given patient at the time it is needed.
- Patient-related issues can include improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education. While patient related issues are listed as a separate cause by some reporting systems, they are often nested within other human and organizational failures of the system.
- Organizational transfer of knowledge can include deficiencies in orientation or training, and lack of, or inconsistent, education and training for those providing care. This category of cause deals with the level of knowledge needed by individuals to perform the tasks that they are assigned. Transfer of knowledge is critical in areas where new employees or temporary help is often used. The organizational transfer of knowledge addresses how things are done in an organization or health care unit. This information is often not communicated or transferred. Organizational transfer of knowledge is also a critical issue in academic medical centers where physicians in training often rotate through numerous centers of care.
- Staffing patterns/work flow can cause errors when physicians, nurses, and other health care workers are too busy because of inadequate staffing or when supervision is inadequate. Inadequate staffing, by itself, does not lead directly to medical errors, but can put health care workers in situations where they are much more likely to make an error.
- Technical failures include device/equipment failure and complications or failures of implants or grafts. In many instances equipment and devices such as infusion pumps or monitors can fail and lead to significant harm to patients. In many instances, inadequate instructions or poorly designed equipment can lead to patient injury. Often technical failure of equipment is not properly identified as the underlying cause of patient injury, and it is assumed that the health care provider made an error. A complete root cause analysis often reveals that technical failures, which on first review are not obvious, are present in an adverse event.
- Inadequate policies and procedures guiding the delivery of care can be a significant contributing factor in many medical errors. Often, failures in the process of care can be traced to poorly documented, non-existent, or clinically inadequate procedures.
Research at Stanford Medicine concludes that “better communication between caregivers reduces medical errors[vi].” The Stanford research found that focused efforts to improve communication quality alone resulted in a 30% decline in preventable adverse medical error events. (A copy of that research and experimental program is available for download at http://www.ipasshandoffstudy.com.) One of the important benefits from communication education and training is the reduction of preventable medical errors due to communication problems, failures and breakdowns. It is well past time that communication become a priority for health care professionals.
[i] Andel C, Davidow SL, Hollander M, Moreno DA., (2012) The economics of health care quality and medical errors. J Health Care Finance, 2012 Fall;39(1):39-50.
[iv] McCullough, Marie (2016) Fighting a deadly chemo error, The Philadelphia Inquiry, November 11, 2016, A2.