THE CMG VOICE

Communication errors lead to avoidable, preventable patient deaths

Over a decade ago, the study “To Err is Human” was published by the Institute of Medicine, and found that between 44,000 and 98,000 patients are killed in hospitals every year due to medical errors.

Then a couple of years ago, the Journal of Patient Safety estimated that 440,000 patients die every year from “preventable” medical errors.

One of the biggest reasons for these deaths is communication failures. This was the key finding of a recent study examining malpractice cases only. This includes failures such as a nurse failing to tell the surgeon that a patient was experiencing abdominal pain and a drop in red blood cells, both alarming signs of possible internal bleeding. The patient later died of a hemorrhage.

Or a diabetic patient calling into an office but the calls were not relayed to the patient’s primary care provider. The patient later died from a condition caused by not having enough insulin.

Or a patient’s cancer diagnosis delayed for over a year because the worrisome lab result was input into her electronic health record but not flagged so her doctor would be alerted.

One group of health care providers is attempting to standardize some of these communications in the hopes that it will prevent these errors from occurring. The system is called “I-PASS,” and it stands for Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by the receiver. While it’s a mouthful, one study has shown that medical errors dropped by 23 percent once I-PASS was implemented in situations where one doctor or nurse is leaving shift and passing a patient on to another doctor or nurse.

To err is human, and unfortunately for medical professionals, they work in a job where erring can mean death. Better systems in place to protect against human errors will be beneficial to the patients, to the health care workers, and even to the hospitals and clinics who employ them. After all, from a purely financial point of view, these errors cost billions of dollars in additional medical care costs, as well as malpractice payments holding them accountable.

You can read a synopsis of this here:

[Communication failures led to 1,744 deaths in five years, US malpractice study finds.](http://www.statnews.com/2016/02/01/communication-failures-malpractice-study/)