Malpractice Threats in Well-Intended Patient Handoffs

Mark Crane


October 04, 2012

In This Article


Life-changing errors in the patient handoff from one doctor to another are becoming more frequent, and they are increasingly occurring among doctors with good intentions who think they're providing fine care.

Some insurers say they've noticed a disturbing spike in the number of lawsuits stemming from avoidable failures when patients are transferred or handed off. The exact increase is difficult to quantify because malpractice cases take years to work through the legal system.

"It's rare for there to be only one physician who follows a patient through the entire course of treatment," said Alan Lembitz, MD, vice president of COPIC, a professional liability carrier based in Denver, Colorado. "Almost all claims have multiple defendants and points of contact."

The potential for mishaps rises dramatically because of the increasing fragmentation in medicine. "The patient's primary doctor may admit him, or maybe it's the emergency department physician," said Dr. Lembitz. "Then he may be seen by 3 or 4 hospitalists and a couple of specialists. Who will handle needed follow-up often isn't clear." When shifts change in hospitals, when one doctor refers the patient to another, and when patients are discharged, vital information often falls between the cracks.

An estimated 80% of serious medical errors involve miscommunication between caregivers when patients are handed off, resulting in severe patient injury or death, delays in treatment, and increased length of stay at the hospital, the Joint Commission's Center for Transforming Healthcare said earlier this year when it released a new program[1] to help fix the broken communication process.

The Problem Is Extensive

Direct communication between hospitalists and primary care physicians is rare, happening only 3%-20% of the time, according to a 2007 study published in JAMA.[2] A majority of hospitalized patients are unable to name their doctor,[3] and a majority of discharge summaries don't highlight tests and studies that are pending.[4]

"There are 4000 handoffs a day in a typical teaching hospital," Joint Commission President Dr. Mark Chassin said. "If 90% go flawlessly, that's still 400 failures per day."

There's a huge disconnect in how "sending" and "receiving" doctors perceive what each is doing -- or should be doing.

For example, a 2011 study in Archives of Internal Medicine found that 69% of primary care physicians reported sending patients' histories to specialists all or most of the time. Yet, only 35% of specialists said they routinely receive the information. Whereas 81% of specialists reported sending their results to the referring physician all or most of the time, only 62% of primary care physicians report receiving the information.[5]

Hospitalists expect that primary care physicians should relay all the previous laboratory and radiographic data that were available. A phone call would be even better, said Dr. Lembitz. "And the primary care doctor is thinking, 'It would be nice if the hospitalist called me back after seeing my patient so that we could actually discuss this case.'"