The Impact of Poor Communication on Medical Errors

Communication with patient or family

Ten days post-hospitalization, an elderly woman with an indwelling urinary catheter presented to the clinic with her daughter to have the catheter removed. As the patient was leaving after the nurse removed the catheter, the daughter asked the nurse if something could be done about her mother’s back pain from lying in bed. As the nurse ushered them out of the room, she assured the patient and her daughter that she would discuss the complaint with the physician. The nurse failed to pass on the complaint. Later, the patient fell at home and was admitted to the ICU with septicemia from an upper urinary tract infection.

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

Communication among providers

Communication failures among providers may be attributed to ineffective closed-loop communication, information lost in the transition of care, or failure to establish clear lines of responsibility. The examples below illustrate these types of errors.

  • Closed loop communication: A patient was scheduled for shoulder surgery. The informed consent was obtained, and the arm was marked by the surgeon to identify the correct surgical area. In the operative suite, the perioperative nurse placed the blood pressure cuff on the patient’s left arm, covering the identifying mark. Fortunately, the correct shoulder was reidentified during the time-out procedure and a wrong-site shoulder surgery was averted.
  • Transitions in care: A radiologist identified a mass on a patient’s kidney; he called the rural clinic and left a verbal message with a staff member to have the provider return his call as soon as possible. The staff member forgot to relay the message. Later, the radiology report was faxed to the clinic and was promptly filed in the patient’s chart for review at the next visit scheduled in six months. The radiologist assumed the clinic had received and reviewed the faxed report.
  • Clear lines of responsibility: An anesthesiologist and a surgeon failed to communicate regarding oxygen use around the surgical field with the simultaneous use of electrocautery during a procedure. The patient sustained extensive facial burns requiring skin grafts. The defense expert was adamant that it was the shared responsibility of the anesthesiologist and the surgeon to protect the patient from a potential fire injury by communicating verbally, rather than simply assuming that the other practitioner recognized the fire hazard.

Communication involving technology

While performing a procedure to repair a torn tendon, the surgeon inadvertently severed a small nerve. A subsequent surgery was scheduled for the nerve repair. When the patient became dissatisfied with the results of the nerve repair, it was discovered that the chart had no notes documenting discussions of the risks, benefits, and likely outcomes of the nerve repair surgery. No formal office visit had occurred. The discussions had taken place via text messages sent to the physician’s cell phone. The messages had not been entered in the patient’s medical record.



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The Doctor Weighs In

The Doctor Weighs In

Dr. Patricia Salber and friends weigh in on leading news in health and healthcare