Clear and effective communication forms the foundation of safe, high-quality medical care. When healthcare providers fail to share essential information either with patients or with other members of the care team, the results can be catastrophic. Breakdowns in provider communication are a major factor in medical malpractice claims, patient injuries, and rising healthcare costs.
While many people assume malpractice results from surgical mistakes or misdiagnoses alone, communication errors are often the underlying cause of these incidents.¹
Types of Communication Errors in Healthcare
Among healthcare professionals, communication errors include:
- Poor documentation
- Insufficient handoff of information during shift changes
- Failure to adequately review medical records
- Pharmacy errors or mistakes in administering medication
In comparison, examples of provider-to-patient communication errors include:
- Inadequate education about medication
- Failure to respond appropriately to a patient’s complaint
- Miscommunication regarding informed consent
- Incomplete follow-up²
Trust and Verify: Failure to Review Medical Records
Believing his staff had submitted an insurance authorization to receive a pacemaker—defibrillator, a cardiologist, Dr. C, reassured his patient and the patient's wife that the authorization had been submitted. Unfortunately, the authorization had not been submitted; therefore, the patient did not undergo the procedure to receive the device and died.
In the subsequent wrongful death suit, his widow claimed that if the Dr. C had followed up on the authorization, he would have discovered it had not been submitted; after which, it could have been completed and her husband could have undergone the procedure, preventing his death.
Key concept: Physicians need to trust their staff but, as in this case, also verify that critical tasks, such as authorizations, have been completed. It is important for all staff to be clear about their office procedures and periodically review processes such as the handling of referrals, authorizations, and other critical communications.³
Medication Refills: Inadequate Education About Medications
A new patient in her early forties presented to a primary care physician, Dr. PC, with a reported 10-year history of eye irritation. She stated that over-the-counter eye drops were no longer effective and requested a prescription medication. Dr. PC diagnosed allergic conjunctivitis and referred the patient to an ophthalmologist.
Approximately five months later, the patient returned with complaints of red, painful eyes. Dr. PC again referred her to an ophthalmologist. Two years after that visit, she re-presented with a cough and sore throat. Dr. PC documented red eyes on examination and issued another referral to an ophthalmologist.
One year later, the patient returned reporting that her eyes had been persistently red for approximately one month. During that visit, Dr. PC prescribed Tobradex ophthalmic suspension and documented instructions limiting use to five days, with a recommendation to see an ophthalmologist if there was no improvement.
The following month, the patient contacted the office requesting a refill of Tobradex. She reported she had seen an ophthalmologist who ordered other eye drops, but that Tobradex provided better relief. Dr. PC authorized the refill of the medication.
Approximately one year later, the patient requested an ophthalmology referral because she believed she had developed cataracts. Subsequently, the ophthalmologist confirmed the presence of cataracts due to prolonged use of Tobradex.
Although the Tobradex labeling warned that the medication should not be used beyond a short course and advised monitoring and caution with prolonged use, the patient filed a lawsuit against both Dr. PC and the pharmacist. She alleged that she did not recall being informed that Tobradex was not intended for long-term use and that she had not read the package insert describing the risks of extended use, including cataract formation.
Key concept: Implementing and consistently following standardized prescription refill protocols, such as reviewing the chart, confirming indication and duration, reconciling medications, and documenting patient counseling at the time of each refill may help prevent inappropriate long-term use of high-risk medications and reduce exposure to malpractice claims.4
Critical Results Not Communicated
A 33-year-old woman presented to the emergency department (ED) with complaints of dysphagia, shortness of breath, and facial swelling. A computed tomography (CT) scan was ordered and revealed that she was suffering from superior vena cava syndrome.
She was admitted under the care of a pulmonologist, Dr. P, employed by the hospital. The patient subsequently underwent a percutaneous transluminal angioplasty performed by an interventional radiologist. The procedure itself was successful, however, upon removal of the sheath, her blood pressure precipitously dropped from 161/90 to 81/50 mmHg. Shortly thereafter, she experienced seizures and became unresponsive. A code was called, and after resuscitation efforts, the clinical team successfully revived her.
Following the resuscitation, Dr. P ordered her transfer to the intensive care unit (ICU), where she remained hypotensive. Believing the patient to be stable, Dr. P left the hospital for the night without personally evaluating her or providing specific monitoring instructions to the nursing staff regarding her condition.
Overnight, the patient's condition deteriorated. Her urine output ceased and she appeared increasingly confused and lethargic. The nursing staff, unaware of the critical significance of her low blood pressure, did not contact Dr. P until the blood pressure had dropped into the 60s, at which point she was unresponsive and exhibited pulseless electrical activity. Despite resuscitation attempts, the patient had died by the time Dr. P arrived at the hospital.5
Key concept: Clearly verbalizing and documenting handoff information helps prevent disagreements among physicians and nurses about what was communicated, which can ultimately strengthen the patient’s position in any potential litigation. In contrast, inadequate documentation of key handoff details can lead to conflicting recollections and disputes later on.6
Dona Constantine, RN, BS, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com
¹Passen, Brian. “How Do Physician Communication Errors Contribute to Medical Malpractice?” Passen Law Group. https://www.pbglaw.com/blog/how-do-physician-communication-errors-contr….
²“Communication Errors in Healthcare.” HHP Law Group.
https://www.hhplawgroup.com/communication-errors-in-healthcare.
³Ownby, Gordon. “Delegating in the Medical Office: Trust and Verify.” Medicine on Trial, 1st ed. (Los Angeles, CA: Cooperative of American Physicians, 2010), 50.
4Ownby, Gordon. “Keeping a Watch on Refills.” Medicine on Trial, 1st ed. (Los Angeles, CA: Cooperative of American Physicians, 2010), 62.
5"Communication failure between pulmonologist, nurses leads to malpractice claim." Pulmonology Advisor. February 2024. https://www.pulmonologyadvisor.com/features/malpractice-claim-from-pulm….
6Ownby, Gordon. “Document the Handoff to Avoid Finger Pointing.” Medicine on Trial, 1st ed. (Los Angeles, CA: Cooperative of American Physicians, 2010), 35.