Malpractice Dangers in the Patient Handoff

Mark Crane, BA


May 17, 2017

In This Article

Communication Blunders Cost Lives and Money

Some examples of malpractice cases that CRICO examined are as follows:

  • A woman's cancer diagnosis was delayed for a year because her lab result was entered into the electronic health record, but wasn't flagged to her primary care doctor.

  • A nurse failed to tell a surgeon that a patient experienced abdominal pain and a drop in red blood cells after surgery—signs of possible internal bleeding. The patient later died of a hemorrhage.

  • A woman's request to be sterilized after delivering a baby wasn't shared with the obstetrician on duty. The patient filed a lawsuit when she became pregnant again.

  • A 63-year-old man saw his primary doctor for chest congestion and shortness of breath. A radiograph confirmed bilateral pneumonia, but lab values also raised concern for possible early congestive heart failure. The patient was referred to a pulmonologist, but the lab findings weren't conveyed to either the patient or that doctor. The primary physician incorrectly assumed that the pulmonologist would access the labs via the electronic record. The patient's pneumonia symptoms improved, but 1 week later he developed severe chest pain and difficulty breathing. At the hospital, he developed pulmonary edema and ventricular dysfunction, and died in the intensive care unit.

The Explosion in the Number of Hospitalists

The growth in the number of hospitalists has been nothing less than phenomenal. About 3500 physicians described themselves as hospitalists in the year 2000. Now, there are more than 52,000, according to the Society of Hospital Medicine.

Although malpractice insurers and patient safety experts believe that these doctors have significantly improved hospital care, a study of malpractice claims by The Doctors Company, the nation's largest professional liability carrier based in Napa, California, found many incidents of preventable harm to patients, often due to a botched handoff.

Studying 464 claims against hospitalists that closed between 2007-2014, The Doctors Company found that communication errors among providers accounted for 23% of the lawsuits.[2]

"In some cases, nurses identified patients who were at risk for deep vein thrombosis or pulmonary embolism or who exhibited changes in neurological status, but they failed to notify a physician," the 2016 report said. "Other cases involved physicians who failed to see or find important clinical information documented in the medical record and, therefore, were unaware of changes in the patient's condition or unaware of alterations to medications, diet and therapies."

Twelve percent of the lawsuits were attributed to communication failures between the patient or family and the health provider. Language barriers were a big problem. "Problems also arose when patients expected to see their family physician in the hospital, and they were surprised to learn that a hospitalist had taken charge of their hospital care."

"The largest number of cases revealed weaknesses in the processes used by members of the healthcare team," the report said. "Important clinical information can be difficult to locate in electronic health records or be obscured by lengthy progress notes resulting from copy and paste over-documentation. Handoffs between hospitalists may not convey critical information and efforts to reach physicians in other specialties are sometimes unsuccessful."

Primary care physicians can do more to improve the handoff and make sure that vital information is transmitted.

"Patients often come to the hospital with no documentation regarding their current or past illnesses," said Darrell Ranum, JD, vice president of patient safety and risk management for The Doctors Company. "Patients may not recall what medications they are taking or why. Use of a common electronic health record will help hospitalists gain a more complete picture by making office records available to them. In situations where hospitalists don't have access to office records, primary care physicians can encourage patients to take a current medication list (or their actual medications) and the summary of their last office visit when they go to the emergency department or are being admitted to the hospital."


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