The Impact of Poor Communication on Medical Errors

By Michelle Swift, RN, JD, CPHRM | Published 12/5/2017 2

doctor sitting alone in hospital corridor on the background of walking colleagues 2048 x 1365

Communication breakdowns are a frequent risk management finding in malpractice claims. The Doctors Company identified communication as a contributing factor in 27% of claims closed from 2012 through 2016. Of those claims, communication was further subcategorized into communication between patient or family and providers, communication among providers, and communication involving technology, including telephone, e-mail, facsimile, Internet, and telemedicine.


Communication with patient or family

Ten days post-hospitalization, an elderly woman with an indwelling urinary catheter presented to the clinic with her daughter to have the catheter removed. As the patient was leaving after the nurse removed the catheter, the daughter asked the nurse if something could be done about her mother’s back pain from lying in bed. As the nurse ushered them out of the room, she assured the patient and her daughter that she would discuss the complaint with the physician. The nurse failed to pass on the complaint. Later, the patient fell at home and was admitted to the ICU with septicemia from an upper urinary tract infection.

The nurse’s communication lapses included failing to ask the patient questions about her back pain and failing to communicate the message to the provider. Had further communications with the patient and the provider taken place, the cause of the back pain could have been explored and a timelier diagnosis could have been made on the upper urinary tract infection.

An essential part of effective communication is taking time to educate patients and families about medications, activities, follow-up appointments, and contacting the physician if concerns arise, such as the continuing back pain in this case example. Developing thorough communication takes practice and time. It is more than relying on others or going through mechanical motions.

When possible, speak with the patient when the family is present. Implement Ask Me 3, the National Patient Safety Foundation’s time-efficient, effective tool that encourages patients to participate in their own healthcare by understanding the answers to three questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?


Communication among providers

Communication failures among providers may be attributed to ineffective closed-loop communication, information lost in the transition of care, or failure to establish clear lines of responsibility. The examples below illustrate these types of errors.

  • Closed loop communication: A patient was scheduled for shoulder surgery. The informed consent was obtained, and the arm was marked by the surgeon to identify the correct surgical area. In the operative suite, the perioperative nurse placed the blood pressure cuff on the patient’s left arm, covering the identifying mark. Fortunately, the correct shoulder was reidentified during the time-out procedure and a wrong-site shoulder surgery was averted.
  • Transitions in care: A radiologist identified a mass on a patient’s kidney; he called the rural clinic and left a verbal message with a staff member to have the provider return his call as soon as possible. The staff member forgot to relay the message. Later, the radiology report was faxed to the clinic and was promptly filed in the patient’s chart for review at the next visit scheduled in six months. The radiologist assumed the clinic had received and reviewed the faxed report.
  • Clear lines of responsibility: An anesthesiologist and a surgeon failed to communicate regarding oxygen use around the surgical field with the simultaneous use of electrocautery during a procedure. The patient sustained extensive facial burns requiring skin grafts. The defense expert was adamant that it was the shared responsibility of the anesthesiologist and the surgeon to protect the patient from a potential fire injury by communicating verbally, rather than simply assuming that the other practitioner recognized the fire hazard.

Communication, both verbal and written, requires repetition and continuous evaluation to identify failure points for refinement. Implementing The Joint Commission’s Universal Protocol to reduce the possibility of wrong site, wrong person, or wrong procedure may help minimize errors, but it should be reviewed periodically for consistency and application as habits and staff change. Policies should require marking the specific surgical site, such as the shoulder, instead of marking a general area, such as the upper arm.

When performing the time-out immediately before starting a procedure or making an incision, all procedure team members should actively participate in discussing the patient’s care. This should include any anesthesia concerns for the patient during the procedure rather than making assumptions based on prior experience and circumstances. Every caregiver has the responsibility to speak up.1

Inadequate lab and diagnostic test tracking is another leading cause of patient injury. Processes should be evaluated frequently for improvement in communication from the time the test was ordered until the time the results were reviewed, documented, and shared with the patient. Not only should an internal system and process be implemented, but we also recommend that providers engage patients to follow up by calling the clinic if they do not receive results.

Related Content: Actors and the Art of Better Patient Communication

Communication involving technology

While performing a procedure to repair a torn tendon, the surgeon inadvertently severed a small nerve. A subsequent surgery was scheduled for the nerve repair. When the patient became dissatisfied with the results of the nerve repair, it was discovered that the chart had no notes documenting discussions of the risks, benefits, and likely outcomes of the nerve repair surgery. No formal office visit had occurred. The discussions had taken place via text messages sent to the physician’s cell phone. The messages had not been entered in the patient’s medical record.

Review or develop clear communication guidelines when using technology (telephone, e-mail, facsimile, the Internet, or telemedicine) while keeping patient privacy in the forefront. All communications involving patient care must become part of the patient’s medical record.

To enhance efficient communication among providers of a patient’s status, consider using the SBAR (Situation Background Assessment Recommendation) format. SBAR is a standardized communication method that provides for the transfer of vital, clear, and relevant information about a patient’s condition in an organized manner in any setting.

By identifying and eliminating the most frequent communication breakdowns in the healthcare setting, errors leading to a patient injury can be reduced.

1. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The Joint Commission website. httpss://

This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.

Michelle Swift, RN, JD, CPHRM


Ms. Swift earned her Bachelor of Science Degree in Nursing from Westminster College in Salt Lake City, Utah. She completed her Juris Doctor Degree at Thomas Jefferson School of Law with a focus in healthcare law and is licensed by the Utah Bar Association.

Prior to joining The Doctors Company, Ms. Swift worked as a medical malpractice case advisor, a pre-litigation chairman, and a medical record review consultant. Ms. Swift has 32 years of experience in a variety of settings, from hospital medical-surgical nursing to pain management and psychiatric inpatient care. As a past president of the Utah Nurses Association and a state lobbyist for more than five years, she advocates for healthcare providers.


  • The culture among nursing in our hospital involves identification of patients primarily by room number as opposed to name. Physicians are contacted with questions regarding “room 583, or ICU 12.” Nurses communicate by referring to “room 948” with sign outs. As a previous chair of both medicine and nephrology and a former chief of the medical staff I have been totally ineffective in significantly influencing this issue. The hospital administration agrees in principle but offers little to no help. I have been unable to find literature that specifically addresses this. Any advice would be appreciated.

    • Docs can help by leading by example. We may not say “Room 583,” but we do say things like the guy with pancreatitis or the woman with one leg. We need to make a point of getting to know something personal about every patient (their names, family members names, job, hobbies, likes, and dislikes).

      I took care of a man in the ER many times. I thought of him as the “frequent flyer with diabetes.” One day I saw him leaving with his mother. He was in his street clothes instead of just lying on a gurney in a gown. I was startled to see that he was quite short (I had never seen him standing up). The three of us started chatting and I learned he was a well-known and admired rock collector. He had a family, he had a passion, and he had a NAME! It changed the way we interacted from that time on.

      Medicine has many ways in which it dehumanizes the people we take care of. We have to consciously break through these barriers to reclaim our collective humanity.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Comment will held for moderation