Communication Errors: A Leading Cause of Mistakes in Healthcare

Having worked in the hospital setting as a Lean Six Sigma black belt and in patient safety/risk management, I’ve led or contributed to many root cause analyses (RCAs) over the years. Using a methodical approach to deduce the root causes of problems, communication failure was always (yes, always) either a contributing factor or the singular root cause of a medical error.

To give you an idea of the types of communication errors I frequently uncovered, here are a few examples that I often ran into:

• A busy physician failing to read their Epic inbox messages
• A practice’s failed attempts to connect with a patient regarding pathology results – eventually leading to the notification falling through the cracks, with disastrous results.

Taking a systems approach, under examination is the question, “How can we support physicians and other healthcare team members to reduce medical errors by improving communication?”

Diagnostics errors

Diagnostic errors are the 6th leading cause of death in the United States and contribute to 80,000 deaths annually.

Diagnostic errors are defined as the failure to: (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient. A type of diagnostic error is delay in diagnosis, and it’s frequently attributed to a communication breakdown. Yet, according to the Institute of Medicine, delay in diagnosis is a “vast blindspot” in our healthcare system that’s not well-studied making it difficult to accurately quantify the impact.

Diagnostic errors are the 6th leading cause of death in the United States and contribute to 80,000 deaths annually.

A recent article published in BMC Family Practice titled, “Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study” explored the causes and solutions of delay in diagnosis within primary care. Over 100 physicians identified main problems and solutions. Suggestions were thematically grouped and scored. The top 3 problems were defined as:

• Poor communication between secondary and primary care – i.e. testing ordered by secondary care was not visible in primary care
• Inverse care law – i.e. those who most need medical care are least likely to receive it. Conversely, those with least need of health care tend to use health services more and more effectively
• Patients attending other services such as walk-in clinics instead of seeing their own GP

The top solutions were identified as:

• A more rigorous system in place for communicating abnormal results to patients
• Direct hotlines to specialists to discuss patient problems
• Clear referral guidelines and pathways for other common conditions (not just cancer)
• Improve handovers
• To have “affordable” GP update courses
• Better training of GPs in spotting warning signs of serious conditions, diagnosis that are easily missed and safety netting
• Review of every delayed diagnosis to learn how, why and whether it could be prevented in the future

Two-thirds of the top problems and 4 of the 7 solutions are, not surprisingly, communication-related. Though all proposed solutions are impactful, perhaps none more so than the last.

Two-thirds of the top problems and 4 of the 7 solutions are, not surprisingly, communication-related.

Physicians are overburdened and under-resourced, but healthcare systems can’t afford to not learn from their medical errors. When errors are due to communication failures, it is necessary to not blame individuals, but to take close scrutiny of the systems within which they work. Generally, when bad things happen, it is the direct result of good people working in flawed systems.

In partnership with physicians, it is the responsibility of the organization, and the owner of the system to support performance improvement efforts (such as RCAs), which learn from errors and create communication systems that set physicians up for success. In highly reliable organizations (HROs), such as nuclear power plants or aircraft carriers, learning from mistakes is foundational to error prevention.

About Author

Stephanie Sargent

As the Chief Clinical and Quality Officer, Stephanie oversees the continued development of the Physician Empowerment Suite©, and ensures the ongoing growth and success of the Suite and other related SE Healthcare programs. Stephanie is a seasoned clinical and Lean Six Sigma professional with more than 22 years of experience in health care. As a certified Lean Six Sigma Black Belt, she is skilled in identifying clinical and operational performance gaps to decrease professional liability risk, meet regulatory and accreditation requirements, improve clinical quality and patient outcomes and reduce waste and inefficiencies.