Communication Breakdowns Drive Diagnostic Failure in Emergency Medicine

By Susan Carr

Communication problems are known to contribute to preventable adverse events of all kinds, including those caused by diagnostic error. The Joint Commission identified inadequate communication as the leading root cause of all reported sentinel events in 1995 through 2007.1 In 2011 and 2012, communication ranked a close third, behind human factors and leadership, and in January through June 2013, rose to second place, behind human factors.2 In 2002, The Joint Commission issued a Sentinel Event Alert on delays in treatment in which it reported that the most common among varied reasons for delay was misdiagnosis, which was found in 23 of 55 cases. More than half (29 of 55) of the events took place in emergency departments (EDs), and 84 percent of hospitals reporting these events identified “communication breakdowns” as a contributing root cause.3

Having studied diagnostic failures in emergency departments for more than five years, CRICO Strategies—a division of the Risk Management Foundation of the Harvard Medical Institutions (a CRICO Company)—has also found that communication failures lead to diagnostic failures in emergency medicine, a leading cause of malpractice claims.

At the 2013 conference of the American Society for Healthcare Risk Management (ASHRM), two directors from CRICO Strategies—Dana Siegal, RN, CPHRM, director of patient safety; and Gretchen Ruoff, MPH, CPHRM, program director—discussed the results of a recent study of diagnostic errors in emergency departments.4

CRICO reviewed more than 10,000 cases asserted between 2004 and 2008, which appear in its Comparative Benchmarking System (CBS), a database of more than 275,000 medical malpractice claims from academic and community health care systems across the United States. The review showed that diagnostic failures cause the most frequent and costly claims against emergency departments.

According to Ruoff, CRICO researchers were surprised to find that the diagnoses missed were not of rare diseases or unusual presentations. Rather, they were often seemingly basic and straightforward: myocardial infarctions, fractures, and gastrointestinal issues. Ruoff reported that missed diagnoses were “happening to healthy patients with uncomplicated histories, and we had significant issues with clinical judgment and communications. We weren’t getting all the right information, we were focused too narrowly and taking the patient down the wrong pathway, sending them out the door oftentimes with something very dangerous.”

Leadership Council Survey

In 2010, CRICO and CRICO Strategies convened the Emergency Medicine Leadership Council (EMLC) to address these diagnostic failures and resulting malpractice liability in emergency departments among hospitals affiliated with CRICO’s Harvard members and Strategies’ national client organizations. Review of the CBS database yielded 479 claims of diagnostic failure (among 872 ED claims between 2004 and 2008), of which the EMLC chose 200 for more extensive study.

The EMLC found that missed or delayed diagnoses were often attributable to missing information—to information that existed at the time of service but was not available to physicians for a variety of reasons when they needed it to inform diagnostic decision-making. In a white paper published in 2011, the EMLC described the range of possible information gaps:

  • the availability of prior historical information from the medical record or referring physician,
  • a change in the patient’s status or a persistently abnormal vital sign,
  • the timeliness of laboratory or radiology data,
  • communication from the consultant physician,
  • miscommunication at patient hand offs, and
  • barriers to effective communication between the nurse and physician caring for the patient.5

In their ASHRM presentation, Ruoff and Siegal described the next phase of work undertaken by the Emergency Medicine Leadership Council. Understanding that missing information and communication gaps were the primary contributors to diagnostic failure, members of the Council led self-assessment surveys in their own hospitals to better understand points of weakness and opportunities for improvement. At the next meeting of the EMLC, members developed strategies to address problems revealed in the surveys, which were then implemented as 4-month-long pilot programs at their hospitals, including diagnostic timeouts, physician-nurse huddles, trigger alert systems, vital sign audits, team training, and simulation exercises.

Real-Time Communications

Among communication gaps, Siegal identified inadequate real-time communication among nurses and physicians as the biggest problem. More than a few respondents to the self-assessment survey reported that they might work an entire shift without ever speaking directly with the RN or MD on their team. According to Siegal, these were the most “concerning” statements in the survey results.

Ironically, electronic medical records (EMRs) contribute to the problem. While there are advantages to recording clinical information in the EMR, it is not effective for communicating critical information in real time. Especially in the ED environment, there’s no replacement for direct, one-to-one communication. Tremendous energy goes into acquiring real-time data and assessments and tracking down patient histories, medication lists, test results, and so on. Those efforts are wasted if the information is not available to those who need it, when they need it, whether because the information is hidden away in the EMR or in another clinician’s head. Siegal pointed out that it can be just as important to make sure the right individuals know what is not known, such as family history, prior treatments, imaging and laboratory results, especially before anchoring on a diagnosis.

In a recent article, Trowbridge, Dhaliwal, and Cosby position communication among other factors that contribute to diagnostic error and should be addressed in medical education.6 In addition to optimizing cognitive abilities and intuitive reasoning, they recommend increasing awareness of systems that affect communication and, therefore, diagnosis:

A systems view of diagnosis regards clinical reasoning as a cognitive process that is dependent upon a number of external factors that impact the ability to gather information, acquire tests and imaging, interpret results and communicate with others. From an educational perspective, a systems approach to teaching diagnostic skills must equip learners with the knowledge, skills and attitudes to interact with people and processes to make a reliable diagnosis.6(pii30)

The experience of CRICO researchers working with many years of coded medical malpractice cases confirms recent research that shows cultural attributes contribute to communication problems.7–9 Rigid hierarchies, a history of disruptive behavior, or fear of punishment can discourage team members from speaking up or sharing crucial knowledge and information. From uninformed clinical consultations to lost radiology reports or unreported status changes, factors that contribute to diagnostic failures in the ED often involve issues of accountability and leadership among team members and in the organization in general.

Pilot Programs

The EMLC white paper describes improvement programs piloted at council members’ hospitals, which Siegal also mentioned and updated in her presentation. The programs fall roughly into three categories:

  • structured communication techniques such as Situation, Background, Assessment, Recommendation (SBAR) and huddles;
  • operational improvements such as Lean; and
  • education and training programs such as team training (i.e. TeamSTEPPS).

Among improvement programs, Siegal reports that CRICO’s emergency medicine simulation program has been especially successful. It has gained traction at seven Harvard institutions, which have used the program voluntarily and were on track to have all 1,500 of their emergency providers complete the program by the end of 2013. The simulation program, which uses case studies from CRICO’s collection of teaching abstracts built from the CBS database, focuses on improving communication. The simulations allow providers to navigate typical scenarios, such as managing the needs of multiple patients as a team, paying attention to how they gather and transmit information, and thinking about how that affects the diagnostic process. Siegal emphasized that departments can develop case studies based on their own experiences and don’t have to have high-tech simulation labs to do this work. Siegal recommends, “Studying these cases and talking about how they interact and intersect with each other is a good place to start a conversation about what’s going on in the ED.”

References

  1. The Joint Commission. Improving America’s Hospitals. The Joint Commission’s Annual Report on Quality and Safety. Oakbrook Terrace, IL: The Joint Commission; November 2007.
  2. The Joint Commission. Sentinel event data: root causes by event type 2004–June 2013. September 20, 2013. Accessed December 20, 2013.
  3. The Joint Commission. Delays in treatment. Sentinel Event Alert, Issue 26. Published June 17, 2002. Accessed December 20, 2013.
  4. Siegal D, Ruoff G. Case study: Communication breakdowns that drive diagnostic failure in the ED. Paper presented at: ASHRM Annual Conference and Exhibition; October 30, 2013; Austin, TX.
  5. CRICO/RMF Strategies Emergency Medicine Leadership Council. Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-Related Errors. Cambridge, MA: CRICO/RMF Strategies; February 14, 2011. Accessed December 20, 2013.
  6. Trowbridge RL, Dhaliwal G, Cosby KS. Educational agenda for diagnostic error reduction. BMJ Qual Saf. 2013;22:ii28–ii32. Full Text. Accessed December 20, 2013.
  7. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-939.
  8. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.
  9. Lucian Leape Institute. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA: National Patient Safety Foundation; 2013.