Communication problems often initiate "cascades" of errors

A report shows that miscommunication, rather than incompetence, usually figures into errors at the primary care level.

By Andis Robeznieks — Posted Aug. 16, 2004

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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.

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Patients seek spiritual talk

Eight in 10 family practice patients in an Ohio study wanted physicians to ask about spiritual beliefs sometimes. The more serious the illness, the more willing patients were to discuss spirituality.

Patients believed that sharing information about their beliefs would affect their physicians' ability to give medical advice, encourage realistic hope and change medical treatment, said the Ohio study in the July/August Annals of Family Medicine.

"The patients want [spiritual discussions] very, very much. Doctors just really don't do it too much. They don't really feel comfortable doing it, even though the patients want it," said Gary McCord, lead author of the study and research coordinator of the Dept. of Family Medicine at Northeastern Ohio Universities College of Medicine in Rootstown.

A questionnaire was completed by 921 patients in the waiting rooms of four family practice residency training sites and one private group practice in northeastern Ohio. Respondents said the most acceptable situations for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%), said the study, "Discussing Spirituality with Patients: A Rational and Ethical Approach." Their most important reason for talking about spirituality was a desire for physician-patient understanding.

During medical care, spiritual inquiry should center around understanding, compassion and hope, the study said. Doctors should identify spiritual referral sources for patients and use them when appropriate. "Our finding about understanding, compassion and hope -- the majority of physicians are certainly capable of taking care of that," McCord said.

--Damon Adams

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External links

"In This Issue: Practice Change and Patient Safety," Annals of Family Medicine, July/August (link)

"Why Isn't It Better?" Annals of Family Medicine, July/August (link)

"Preventing Errors in Clinical Practice: A Call For Self-Awareness," Annals of Family Medicine, July/August (link)

"A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors," Annals of Family Medicine, July-August (link)

"Event Reporting to a Primary Care Safety Reporting System: A Report from the ASIPS Collaborative," Annals of Family Medicine, July-August (link)

"Patient Reports of Preventable Problems and Harms in Primary Health Care," Annals of Family Medicine, July-August (link)

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