Common Factors | Fall 2022

Top Risk Driver— Team Communication

A striking 35%—more than one-third—of Constellation’s medical professional liability (MPL) claims include at least one issue involving communication. The alarming truth is that there are many complex ways communication breakdowns can occur, at many points in care, and with many of the people involved. Communication issues can occur during the diagnostic phase, resulting in wrong or delayed diagnosis. Issues can arise between care team members—perhaps someone missing significant notes in a patient’s chart that results in an error—or between the care team and a patient, senior living resident or family member. And communication problems can occur postsurgery, as a patient or senior living resident is transitioned to a new facility or care team. In our analysis of Constellation’s MPL claims, communication breakdowns account for 39% of costs—a total of $227 million over 10 years. And often, a single harm event or claim can involve multiple communication breakdown factors, complicating things even further.

Who? What? Where? The Many Opportunities for Breakdowns

Claims involving breakdowns in communication are often so complex that they can be similar to a game of Clue™. Was it the Nurse with the Patient’s Medical History in the Operating Room talking to the Surgeon? Or the Lab Technician with an x-ray in the Office of the General Practitioner? Or the Physician Assistant consulting with a Specialist… informing the Patient in the Clinic?

Among all the communication breakdowns that can lead to MPL claims, those that occur within the care team lead to the highest indemnity costs. Among all allegations, team communication factors account for a total cost of $151 million.

Based on our analysis, the locations where care team communication breakdowns are most likely to occur are:

  • Patient or senior living resident room
  • Clinic
  • Labor and delivery
  • Operating room
  • Emergency department 

Team communication breakdowns in labor and delivery represent only 5% of claims, but they account for a disproportionately high 21% of costs. And claims involving team communication breakdown are serious—50% of these claims result in high-severity harm such as death, quadriplegia and brain damage.

Case by Case

Case 1

Buried results allow colon cancer to progress undetected.

A 16-month delay in diagnosing colon cancer occurred when an office team member and physician failed to recognize an abnormal pathology report following a colonoscopy on a 62-year-old woman, because the information about the cancerous polyp was buried in the report. A letter sent to the patient erroneously identified the polyp as benign. The cancer advanced to Stage IV during the delay.

These contributing factors played a role in the allegation of failure, delay or wrong diagnosis:

Failure to read another clinician’s note

Loss of critical communication at transition of care

Case 2

Communication breakdown and gaps in transition result in death.

During a handoff of care, a delivering obstetrician failed to mention that the 36-year-old woman he had just performed a cesarean delivery on had a platelet disorder. The lack of this vital information led to a failure to appreciate hemodynamic changes causing a surgical delay that contributed to the death of the woman.

These contributing factors played a role in the allegation of mismanagement of a surgical patient:

Failure to communicate about the patient’s condition

Loss of critical communication at transition of care

Case 3

Poor monitoring and lack of communication leads to sepsis.

An 83-year-old woman in a senior living center for rehab died from sepsis due to failure to monitor and appropriately treat her skin pressure injuries. The senior living care team did not communicate with the woman’s treating clinicians about the status of her pressure injuries and did not clarify who among her various providers was managing this condition.

These contributing factors played a role in the allegation of mismanagement of medical treatment:

Failure to communicate about the resident’s condition

Loss of critical communication at transition of care

Team Communication Risk Management Tips:

  • Invest in team training and tools to improve team communication such as TeamSTEPPS, SBAR and I-PASS.
  • Assess your safety culture and the prevalence, context and impact of behaviors on team communication. Build a strategic plan to address areas of concern.
  • Commit to an organization wide culture and environment that fosters professional, open communication and supports team collaboration.
  • Develop and implement professional behavior policies, including expected behavior standards and a process for addressing disruptive behavior.

Presenter Lori Atkinson

Content Manager and Patient Safety Expert