A 79-year-old woman was brought to the Emergency Department of the local hospital by her son with complaints of dizziness, weakness and a history of having fallen at home. The hospitalist admitted her for observation with a diagnosis of atrial fibrillation and hypokalemia. The hospital nurse assessed the woman as being at risk for falls and implemented fall precautions. During the night, the woman got out of bed without requesting assistance and was found on the floor of her hospital room unable to get up. The nurse documented that the woman denied complaints and that there were no visible injuries. The nurse did not contact the hospitalist or the patient’s son to report the incident. The next day when the hospitalist was rounding, the woman’s nurse communicated the fall incident. The hospitalist noted left arm weakness and ordered an X-ray, which showed a fractured ulna. No other testing was done. Later that evening, the woman’s son told the nurse that his mother was also complaining of hip pain. The nurse called the hospitalist, who ordered X-rays, which showed a fractured hip. The next morning, an orthopedist performed a closed reduction of the hip fracture and open reduction of the arm fracture. Following surgery, the hospitalist ordered the woman to be transferred to a skilled nursing facility (SNF) for rehab prior to going home. The admitting orders included an anticoagulant medication and orders for lab testing. The transfer information did not include information about her fall history and the now increased risk of fall-related harm due to the anticoagulant therapy. Two weeks later, the woman fell in her room at the SNF, striking her head on a table. She was transferred to the local hospital where she died later that day from an intracranial hemorrhage. Her family filed a malpractice claim against the hospital and the SNF.
The details of this case highlight a typical pattern found in malpractice claims: more than one communication-related contributing factor gone wrong within the care team. Constellation data on medical professional liability (MPL) claims show that while communication breakdowns resulting in claims are fewer within care teams than between care teams and patients/residents/families—only 43% of claims occur between care teams versus 66% between the care team and the patient/resident/family—the breakdowns within care teams tend to result in more harm, which drives higher costs.
Care team members may include physicians, nurse practitioners (NPs), physician assistants (PAs), nurses (RNs), techs, certified nursing assistants (CNAs), lab techs or radiology professionals. According to the data, the most frequent team communication breakdowns involve:
Fifty percent of claims involved high severity harm. Shockingly, but perhaps not surprisingly, analysis of claims resulting from care team communication breakdowns reveal that half of the reviewed events resulted in high levels of harm, such as death, quadriplegia or brain damage
What does poor communication cost? An analysis of Constellation claim data shows that communication breakdowns are a contributing factor in 35% of harm events, accounting for a disproportionate 39% of costs—roughly $223 million over 7 years.
What does poor communication cost? An analysis of Constellation claim data shows that communication breakdowns are a contributing factor in 35% of harm events, accounting for a disproportionate 39% of costs—roughly $223 million over 7 years.