Complex systems are prone to communication breakdowns, unless there is a concerted effort to properly share necessary information. Unfortunately, the failure to communicate is all too prevalent in the delivery of medical care.
Dr. Peter Pronovost, a leading patient-safety experts at Johns Hopkins University, estimates diagnostic errors are responsible for the deaths of 40,000 to 80,000 hospitalized patients every year. That is a shockingly high number.
With so many errors being made, injured people naturally turn to the legal system seeking proper compensation. And indeed, a recent study by the State University of New York (SUNY) Downstate Medical Center in Brooklyn found medical malpractice related to diagnostic errors is on the rise.
Hospital Errors in Communication Lead to Poor Care
Many medical malpractice claims involve a breakdown in communication between diagnosticians and treating physicians. These breakdowns include both doctors and patients failing to receive results of tests, as well as delays in sharing the findings of tests.
Who hasn't been in a doctor's office as they scurry from examining room to examining room? The time pressure of seeing as many patients as possible a day makes simple mistakes in communicating - and on the other side, receiving and digesting - important information more likely.
In other words, many medical specialists do not only often fail to communicate properly with patients. There is also often a communication gap between doctors themselves, when they fail to close the loop on conveying the results of diagnostic tests. As a result, claims for medical malpractice increased by an estimated $4.7 million annually between 1991 and 2009.
Why are there so many communication breakdowns in the practice of medicine today? It's not enough to say that modern medicine has become exceedingly complex, thereby multiplying the chance for communication errors to occur. Nor is it sufficient to say that doctors are practicing too much defensive medicine, ordering tests that aren't really needed.
The reality is that, far too often, doctors and other medical staff lose sight of the importance of good patient care. Good care means ordering only those diagnostic tests that are truly needed and following through on those. Healthcare providers have it in their power to close the communication loop, and they need to do a better job of doing so.
In some health systems, this process is already underway. For example, the Veterans Health Administration has begun developing programs for following up on lab results that are abnormal. Electronic medical records may help in implementing programs like these in New York and around the country.
Malpractice and Failure to Diagnose
Insurance companies, hospitals, and self-styled proponents of "tort reform" like to argue that fear of lawsuits results in too many tests. It should be noted, however, that ordering too few tests is also an issue and can lead to misdiagnosis or failure to diagnose cancer.
Missed diagnoses most often include various types of cancer, infection, fractures and myocardial infarctions or heart attacks. Healthcare providers need to work on "closing the loop" through checklists and other safeguards so that lab results do not get lost. Primary care doctors and specialists also need to make sure to actually communicate with each other, so that patient care is paramount.
