Communication problems often initiate "cascades" of errors

The underlying cause for errors in primary care diagnosis or treatment more often than not could be miscommunication, according to a study in the July/August issue of the Annals of Family Medicine.

"Errors in diagnosis and treatment are often caused by errors in communication and not incompetence," said Steven H. Woolf, MD, a professor of family medicine at Virginia Commonwealth University in Fairfax, who co-authored the report.

The study analyzed 75 error reports from 18 family physicians in five states and concluded that a chain or "cascade" of errors was documented in 77% of the incidents. A full 80% of the error chains were initiated by miscommunication, including breakdowns between physician colleagues, misinformation in medical records, mishandling of patient requests and messages, inaccessible records and inadequate reminder systems.

"Many errors arose from specimens being mislabeled and charts being misfiled or missing," Dr. Woolf said.

Because so many diagnostic and treatment errors had their origins in miscommunication, Dr. Woolf and his colleagues suggest that safety initiatives should "focus less on professional interventions to improve clinical judgment and more on management systems to enhance the quality of information transfer."

Although he said most "docs in the trenches" are not inclined to perform a root-cause analysis on reported errors, Bruce Bagley, MD, medical director of quality improvement for the American Academy of Family Physicians, agreed that clear communication would go a long way in improving primary care safety.

"In the big picture, miscommunication is the upstream cause for a lot of problems," he said. "There's the picture of a doc just barking orders at a nursing station and walking away. That's the antithesis of patient safety as far as I'm concerned."

Dr. Bagley said staff has to be "empowered" to speak up when instructions are not clear; special care has to be taken when speaking to patients using an interpreter or when patients are not using their first language; and medical jargon should be avoided.

"It's just as easy to say 'kidney' as it is to say 'renal,' " Dr. Bagley said.

Dr. Woolf noted how safety research is evolving from its origins of picking off the "low-hanging fruit" of obvious hospital safety problems, to looking at how errors occur in the location where most patients get their care: the primary care doctor's office.

"There is a growing interest in attempting to understand errors in the primary care setting," he said. "Finding those types of solutions is more challenging, but the payoff is that the improvements in health care are going to be great."

A reflection of the growing interest in primary-care patient-safety could be found in the current issue of the Annals of Family Medicine, which includes two editorials and four reports on primary care patient-safety studies. These include Dr. Woolf's report on miscommunication and a study that looked at "reframing" questions that need to be asked when an initial diagnosis appears to be problematic.

Just as most patient-safety research has focused on hospitals, much of it has also looked at system causes. In this study, however, Ronald Epstein, MD, concluded that "there are elements that can and should be attributed to individual factors."

He said these are errors caused by failure to reframe an original diagnosis that automatically came to mind (for example, it's flu season, a patient has flu symptoms, so it's assumed the patient has the flu) and the premature closing of a visit to avoid confronting inconsistencies with this diagnosis.

"Sometimes a physician needs to say, 'This doesn't seem to fit, let's take a step back and look at it a different way,' " said Dr. Epstein, a professor of family medicine and psychiatry, and associate dean for educational evaluation and research at the University of Rochester in Rochester, N.Y.

Dr. Epstein said doctors need to develop "somatic markers" that alert them to fatigue leading to "low-level decision-making." These include noticing when doctors are feeling rushed or that handwriting is deteriorating.