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When information falls through the cracks, diagnoses are missed, treatment is compromised and patients are harmed. Errors often occur because information is not recorded, misdirected, never received, never retrieved or ignored. For example, when I ask a doctor if they review nurses notes the typical response is sometimes or rarely. I recently had a doctor tell me that he does not review the nurse’s notes in the electronic medical record because he cannot find the nurses notes! This often results in missed opportunities for doctors to prevent catastrophic consequences to their patients.
Patients are also at an increased risk of suffering from a catastrophic injury due to the failure of health care providers to communicate with each other during the transition of responsibility from one provider to another provider. These transitions are commonly referred to as patient hand-offs. The Joint Commission recently published a Sentinel Event Alert on this very topic. See Inadequate Hand-off Communication, Issue 58, September 12, 2017. Go to www.jointcommission.org The medical literature estimates that communication failures contribute to patient harm in 30 to 50% of medical malpractice cases.
The above referenced Sentinel Event Alert suggests that health care providers should take seven actions to decrease the problems associated with patient hand-offs: 1) Demonstrate leadership’s commitment to successful hand-offs and other aspects of a safety culture; 2) Standardize critical content to be communicated by the sender during the hand-off-both verbally (preferably face to face) and in written form; 3) Conduct face-to-face hand-off communication and sign-outs between senders and receivers in locations free from interruptions; 4) Standardize training on how to conduct successful hand-off –from both the sender and receiver; 5) Use electronic health record capabilities and other technologies-such as apps, patient portals and telehealth-to enhance hand-offs between senders and receivers; 6) Monitor the success of interventions to improve hand- off communication; and 7) Sustain and spread best practices in hand-offs, and make high quality hand-offs a cultural priority.
The lack of a policy concerning training or standardized content of information necessary for a safe hand-off is evidence of a systemic failure. In a quest to find out why something occurred in our medical malpractice cases and how it can be prevented we always think about these seven actions that are recommended and find out what the Hospital is doing to comply.
The haphazard manner in which many Hospitals seem to approach hand-off communications is the opposite of a careful systematic approach that will protect patients from preventable medical consequences that often follow. We always look for these institutional failures in our medical malpractice cases.
If you think you have suffered an injury due to the failure of your health care provider to communicate with each other, call us. We can investigate and find out if you are the victim of a preventable medical error.
If you have been the victim of medical malpractice, seek the counsel of an experienced attorney.