Communication boo-boos are still buzzing in healthcare! Is it spinning more harm to the patient? How to fight back?

Reader guidance: This article specially discuss on 'healthcare communication errors and its impact on safety’. All information assembles from Google search. If you’re not interested on this topic, please discontinue reading.

The words "First, do no harm" is an ethical practice form the core of all caregivers that actually derive from the physician's ‘Hippocratic Oath’ before they provide service to the patient. The first step is doing no harm, though, ensuring that both parties are on the same page regarding health safety issues. Both must understand the nature of an illness, the treatment options, and the goals of care and how they fit in both the physician's and the patient's values and beliefs before care is started. Reaching that point requires a close relationship and trust between physician and patient. However, the effective communication on which such relationships are founded often fragile, creating obstacles to care, increasing healthcare costs and even causing patient's harm. Good communication between physicians and patients and, among the other healthcare providers is the foundation of their relationship, and is critical to good medical care. Good communication leads to better overall health outcomes, fewer hospitalizations, lower healthcare expenses, greater patient satisfaction, fewer malpractice suits and greater physician job satisfaction. With all of that said over the years, the value that the health care system places on the communication between health providers and patient has markedly declined. This is evidence that communication play a crucial role in providing top quality patient care. Any breakdowns in communication can lead to serious problems, such as patient complications or even deaths.

The single greatest misfortune in health and science right now is the inability to communicate well. And no one escapes a share of the responsibility. Doctors don’t talk to patients, doctors don’t talk to doctors, and nurses or other healthcare providers don’t talk to doctors and vise-versa; even electronic health records (EHRs) and IT software system don’t talk to anyone or anything, and on and on. Thus, poor communication, little communication or no communication at all can be blamed for significant flaws and failures in the health delivery system. As technology better enables us to share everything about our lives, connect data like never before and consume information, we must not forget that we need to improve how humans communicate as much as–if not more than–how our electronics do. Here are few instances where communication slips in healthcare.

1. Do Not Talk To Each Other-(Caregivers): Healthcare providers move in into the health field because they care about people. They want to make sure that people feel better. And it’s the passion that makes good providers great. But providers whether it to be a doctor, nurse, physiotherapist, dietitian, other caregiver, social worker or others in the system do not talk to one another as a single care-giving team should. Most importantly physicians overlook nursing note or other caregivers note and fail to understand the current situation or miss any alarming situation of his or her patient that lead to injury or harm to the patient. In fact, it is estimated that 30% of malpractices cases between 2009 and 2013 were a direct result of communication failures. Although healthcare providers are increasingly burdened with growing caseloads, limited resources and complex eMR record systems, the inability or unwillingness to make coworker interaction a top priority is literally harming the patients.

2. Do Not Talk To Each Other- (Hospitals): Unless hospitals are in the same system, they are notoriously competitive with one another, even under same corporate group; they fight each other with business sharing. Even, they don't share patient record while patient is seeking for second opinion or follow-up to other hospitals. There is no unique platform where hospitals can share their challenges and learning lesson especially in patient care. There is no strategy to cooperate with each other. A further, proper incentive is not in place to encourage sharing between systems or sites, even those that do belong to one corporate company. According to Accenture survey report, only in USA, the hospitals are wasted about $12 billion a year due to poor communication. And that isn’t counting unknown costs incurred by a patient once they have left the hospital or the costs of second opinions, follow-ups in other facilities and clinics, or providers who order unnecessary tests due to not being able to see previous results.

3. No one Have Their Own Records: Patients who request access to their own medical records face a cumbersome and outdated process requiring long waiting periods, even up to a month, payment for each and every page of their medical record copy, and fax machines. Despite the rise of EHRs, this process has yet to change and continues to prevent patients from accessing information on their own health. This is another weird situation where patients haven’t own their health record. If provider can be granting access to this line of communication may lead to improvements in understanding and recalling doctor’s orders. In fact, study shows that patients who received rapid access to clinical notes improve adherence to medications by over 60%.

4. Do Not Talk To Each Other- (EHRs): Communication between multibillion dollar Electronic Health Records (EHR) is almost missing, as if the companies lose competitive advantage if they share data. Additionally, hospitals do not readily exchange records, despite calls for interoperability. This is not because they don’t value their patients, but they have no incentive or contract link to share their statistics with their competitors. Also, data confidentiality act, patient's confidentiality right and secure communication channels is fundamental issue to share data. Most people feel EHR systems only contain patient data. But it is more than patient personal data. A significant portion of any EHR contains more hospital and provider information like clinical progress note, diagnostic reports, even how long the wait was for a blood draw or a lab test to be assessed. Additionally, EHR vendors have a huge interest in protecting their proprietary technology and patient confidentiality. Based on demand, what vendors care about most is the collection of data and ready to use by users, not patient outcomes. For any health system to be patient-centered or value-based, EHRs have to be held accountable to patients, not hospitals.

5. Do Not Talk To Each Other- (Medical Equipment's and it's system): The hospital usually adopted several medical equipment systems during its lifetime. This is due to enhance cooperation and collaboration among the departments, introduce of new equipment or technology or up-gradation of old system. However, each medical equipment system in the hospital is unique and single vendor involved within the system. Even within eMR, PACS (Picture Archiving and Communication Systems) medical imaging system may not integrate with others eMR component if the hospital buys PACS system from other sources, similar situation also happen in LIS (Laboratory information system), Queuing system unless the hospital buy everything from single source which is comparatively expensive. And most worse if hospital buys equipment’s from different vendors like Phillip system doesn’t talk with GE (General Electric Co) or Siemens or Hitachi Medical or Johnson & Johnson or Toshiba (TMSC) or Medtronic equipment systems. Even the operating module is different in every system with the same clinical category equipment. Thus hospital is in worse situation to integrate all those systems in one platform. That’s creating confusion among the healthcare providers which may leads to patient’s harm or injuries.

6. Do Not Correlate-Uniqueness EHR Coding: EHR problems are not, however, limited to vendors like Epic, Cerner or All scripts. The problems begin at step one of users use on how data is to be entered. Every healthcare provider is reflecting uniqueness and therefore, they code, prescribe, diagnose, misdiagnose and scratch notes scripts design is unique, don’t correlate with each other. However, patients are also individuals, and no two patients or cases are identical. Therefore, it is no surprise that when databases are merged or crosswalks created a lot of information goes missing or is misaligned. This is undesirable as because patient lives are at stake.

7. Do Not Talk To Each Other- (Scientists): The foundation of evidence based medicine and good healthcare is determined by quality research. Without the brilliant minds and risk-taking hypotheses of researchers, little progress would be made in healthcare improvement. Yet scientists around the world are ruthless at sharing their work data and research protocol unless published. This includes presenting raw data (which should have for reproducibility), status of current projects, failed projects (can learn a lot from failure) and journal paywalls that inhibit learning. All of which mean that work is duplicated, funding is wasted, people are left in the dark and our smartest scientists are not collaborating in ways that promote best outcomes. The best thing researchers/ scientists can do to move their work forward is to look up from the bench and engage each other, as well as the community for better results.

8. No one Talks To-(Ministry of Health): People try to improve healthcare as well as the healthcare organizations also try. But very few are able to get through to those who govern. In most cases, when a legislator takes up a cause in healthcare it is because it impacts someone’s love or someone in their jurisdiction. Unluckily, this means a lot for extensive health issues like chronic diseases and social health determinants go unaddressed. Moreover technologies with potential will never see the light and obvious solutions like food security and research funding become diverged by political consideration rather social needs. It also creates a negative feedback loop where health experts and community members feel ignored and unappreciated, thus creating then into three wise monkeys ( they’re Mizaru, covering his eyes, who sees no evil; Kikazaru, covering his ears, who hears no evil; and Iwazaru, covering his mouth, who speaks no evil) in the system. Thus they drive for more relationships with private donors than those who govern.

9. Media Loves Breaking News: Like their readers, listeners and watchers, media professionals want to hear about the newest and latest information medicine and science have to offer. They always in search of breaking news, creating enormous publicity in the community rather disseminate value added information. This proves that we don’t learn from our own mistakes. While breakthrough technologies and up-and-coming trends are important to share, basic understanding of health and science is often lost or neglected. Or, the passage of time proves that the “next best thing” wasn’t the cure-all it was touted to be. With so many social media and media outlets, the world is now full of “experts” ready to steal a headline. Thus, before sharing information, media need to ensure that due diligence has been done, and scientists need to learn how to communicate their work.

10. Media Is Not Expert At Interpreting Scientific Data: Whether the media person is in question as good communicator or not, current methodologies and mediums for disseminating complex scientific data can lead to confusing or conflicting conclusions. Technical topics require a lot of definitions, unfamiliar terms and acronyms that all of which can make even the most interesting of subjects unreadable to people outside the scientific community. Finding ways to increase media expertise in health interpret between the good and bad science and connect effectively with all people will increase engagement and result in more perspectives to add to the scientific dialog. Further, public media campaigns do have the power to change public health behaviors.

Thus, healthcare workers today recognize that poor communication is perhaps one of the most prevalence problems in healthcare. A number of studies has looked into the causes and outcomes of poor communication in healthcare facilities, and it appears from these studies that the problem is pressing enough to warrant the attention of not just health care workers, but also the general public. One study conducted in the late 1990s found that poor communication was responsible for causing between 44, 000 and 98, 000 patient deaths annually in US hospitals alone. Other studies suggest that poor communication was one of the leading causes of preventable deaths in hospitals. These worrying reports have spurred a number of worldwide efforts to exhaustively characterize the factors that lead to poor communication between physicians and their patients; Physicians, nurses and patients don't talk like they used to. There is a noticeable lack of communication between these three parties, and it is declining patient care both in quality and satisfaction. The number one thing broken to the healthcare system is communication. From the time a person is diagnosed with a condition, while he or she is in the hospital, and after discharge, communication is the key connecting dots for follow up treatment plan and his or her satisfaction. Therefore, patient satisfaction is an integral part of a successful healthcare program and it should be top hospitals centered around on this element. One of the hospitals CEO said earlier that 'his goal is to be the safest hospital in the region.’ Today it's not enough. Today the top strategic priority is to create an ideal healing experience and address the patient needs.

A new report shows just how much poor communication impacts hospital care. The Controlled Risk Insurance Company, CRICO/Risk Management Foundation of the Harvard Medical Institutions looked at over 23,000 medical malpractice lawsuits and claims where patients suffered some types of harm. Out of all these cases, it identified over 7,000 (30%) where the problem was directly caused by miscommunication of certain facts, figures and findings. According to the report, communication errors don’t just happen because someone doesn’t fully understand what a doctor or nurse is saying. Errors occur because information is unrecorded, misdirected, never received, never retrieved or ignored.

Overall CRICO estimated these errors cost the healthcare system $1.7 billion, including the price tag of hefty malpractice payouts for serious injury or death. The errors occurred in the inpatient setting, the outpatient setting and the emergency department. Injuries to the patient caused by these errors were mostly of high and medium severity. Out of all the high-severity injury cases reviewed, 37% involved some sort of communication failure. Over a quarter of malpractice cases involving surgery, and 32% of all nursing cases, were caused by a lack of thorough communication in some aspect of patient care. The common communication problems happened among providers, as well between doctors and patients. In some cases, a combination of both issues caused patient's harm. The most common provider-to-provider communication breakdowns were: (1) miscommunication about the patient’s condition, (2) poor documentation, and (3) failure to read the patient’s medical record especially doctors overlook nursing or nutritionist or physiotherapist note. And common provider-to-patient communication issues involved: (1) inadequate informed consent, (2) unsympathetic response to a patient’s complaint, (3) inadequate education (such as about medications), (4) incomplete follow-up instructions, (5) no or wrong information given to patient, and (6) miscommunication due to language barrier.

What are the causes of communication breakdowns? While each case is different, CRICO identified several common problems that play a role in communication breakdowns in hospitals, such as workload pressure, problems with a hospital’s electronic health records (EHR) system, workplace culture and even just distractions. There are also unexpected circumstances that cause communication breakdowns including familiarity. CRICO cites a study that found more communication breakdowns occur among people who know each other than between strangers. Reason behind it is people think they can use shortcuts in how they express themselves because they assume the other party will understand. However, this assumption can be deadly in the hospital setting. It is said time and time again: the key to any relationship is communication. Yet a lack of communication remains the biggest barrier to patient health outcome and patient experience; and thus, it is the number one cause of adverse events. There's a breakdown in the relationship from the absence of a human touch or voice or a connection by voice and it's the loss of the narrative. This disconnect is present in different processes of the healthcare system and often mirrors breakdowns in leadership and hospital culture. One such element that disrupts the physician/nurse dialogue is the electronic health record. The EHR has been praised for its data aggregation and analysis capabilities, but it as a communication barrier between physicians, nurses and patients. It's a necessary tool, but with a limitation that we've lost the narrative of a doctor and nurse talking to each other about the patient. Instead, they enter their plan into a computer versus having a dialogue with somebody by voice. These new technologies are removing the physical presence of physicians and nurses from patients' bedsides, inhibiting the physician/nurse relationship once dominant in healthcare settings.

How to fight back? There are several strategies hospitals have successfully used to fight the costly, dangerous problem of miscommunication. Besides regular teamwork training with a focus on making sure clinicians communicate clearly and directly with each other, some have tried to eliminate mis-communications in an area where they commonly occur is patient hand-offs. Hospitals have cut down on misinformation using the I-PASS (illness severity, patient summary, action list, situation awareness and contingency planning, synthesis by receiver) method during shift changes and other transitions of care. I-PASS or S-BAR (Situation, Background, Assessment, and Recommendation) is nomenclature tools to adapt to ensure all information is communicated when providers perform hand-offs. Nine hospitals used this strategy as part of a research study to boost patient safety. These facilities saw a 30% decrease in preventable medical errors due to improved communication of key information. Other ways hospitals have improved communication include: (1) role playing and safety drills so providers can practice the communication skills they learned in training, (2) direct observation of procedures by department chairs to identify and correct gaps in teamwork, and (3) EHR updates that help doctor’s better document important details about the patient’s condition. Whatever tactic the hospital chooses, it needs to make sure all forms of communication involving clinicians are top-notch. Developing and enhancing providers’ written and oral communication skills can prevent big errors that both hurt patients and bring negative attention to the hospital.

If communication issues are eased, it is potential for improved patient health outcome and care quality in several healthcare processes. To begin, healthcare providers should focus on balancing empathy and efficiency. The human experience is a significant player in patient health outcome, but it tends to fall to the wayside when healthcare systems look to improve efficiency in their processes. Efficiency is about taking out seven types of waste. Hospitals should identify the gaps in empathy and communication and develop clinical and process innovations that improve the human experience that they can put back into the system.That creates an ideal experience for the patient. Technological innovations are often efficiency driving tools, but instead of completely ignoring technological efficiency for the sake of strengthening communication, hospitals can use technology to enhance communication if it is integrated in an appropriate manner. For example, the patient discharge process is full of paperwork and lengthy instructions that can be overwhelming to patients and time consuming for nurses. Instead of giving patients ‘sheets of meaningless paperwork’, it is suggested to be implementing an application that creates an audio and visual recording of the discharge instructions to add a point of human contact to the process. Healthcare can take example from aviation industry where airlines are now showing safety tips video for understanding the various anticipated risks and how to cope up. Similarly, hospital can provide common disease oriented clinical care video with nutrition and medication safety tips for the discharged patient. This video can also include follow up instruction, wound care for surgical patient and when to contact hospital emergency. Besides, transitions and hand-offs between units and floors also present a risk for miscommunication that could be remedied by appropriately integrated technology. Instead of solely relying on paper checklists and verbal communication, suggestion to be developing an electronic hand-off system that can help ensure vital information is not omitted.

Addressing these communication barriers provides the obvious benefit of better care, and improves satisfaction within the key hospital metrics. There's a direct correlation between patient experience and, quality and safety. When we truly listen to the voice of patients and understand what matters most to them, we improve compliance, engagement and loyalty to the hospitals. Healthcare technology is a perpetually innovative field that will continue to introduce tools and devices that will expand the scope of what is humanly possible, but healthcare providers cannot solely rely on technological advances to help people get better. It is identified that only 20 percent of healing is linked to technology. The other 80 percent is human-to-human interaction and the relationship between doctor and patient. It is also observed that more healthcare providers re-centering their priorities on patients. The whole world is finally focused on what matters to patients and, the hospital is making the greatest treads in improving the quality and safety, and financial keys are focused on improving the patient experience. Trust has always been essential to medical care. Of what use are the best communication skills, empathy, or clinical knowledge if patients don’t trust the advice and information that doctors give to them! First; this is precisely because this reliability is so central to understand of being a physician. For, in today’s medical world, the lines are blurring between doctors’ making their clinical decision and their business decisions. The patients grant their physicians access to their bodies and allow them to place us in situations of great threat. Without trust, the patients could not emotionally undergo many medical treatments. But more and more, a visit to the doctor can become a business meeting and more specifically, a sales meeting where very expensive goods and services are sold to patients. While facing this fact can be emotionally difficult for patients making potentially life changing medical decisions, it allows them to navigate more effectively in this fearless new world of medicine. If the physicians are thinking and acting more like business people, so must patients too.

However, the situation is changing rapidly. There are lots of external factors pressing to keep change in the current system. Let’s see how Ms. Hanh’s experiences on her last emergency department visit of a future hospital when she is in severe abdominal pain. Ms. Hanh Nguyen is a 30-year-old female who has a sudden onset of severe abdominal pain that radiates into the back? She calls her primary caregiver, Dr. David, who tells her to call an ambulance to bring her to the ‘Future Hospital’ emergency department (ED). Dr. David clicks on a Web page for the ‘Future Hospital’ Emergency call-in program. He imports his last progress note with Ms. Hanh’s history and adds a personal note describing his concerns that the patient’s has a history of several cramping colic pain that can lead to an acute pancreatitis or pancreatic cancer! The ED immediately receives the on-line submission and begins preparations for the patient’s arrival while the ambulance is still enroute. Paramedics, using inter-operable communications systems that give them equal capability to communicate with fire and police agencies on one hand and hospitals on the other, inform the ED that Ms. Hanh’s vital signs are stable but she is in severe pain. The emergency physician advises them to administer a dose of intravenous morphine and carefully monitor her blood pressure, oxygenation, and respiratory rate. Upon arrival, Ms. Hanh is rapidly transported to a preassigned room, where the emergency physician, Dr. Duc, and his team are waiting. While the nurses take her vital signs and the doctor examines her, a clerk arrives at the bedside with a wireless laptop. After the initial evaluation, she collects the information necessary to register her in the system without delay. The paramedics complete their run report on a tablet computer and use the wireless network to beam it into the hospital databases.

Ms. Hanh is in too much pain to recall all of his medications accurately. Dr. Duc probes a clinical data-sharing network, which compiles a list from the computerized records of local pharmacies. The doctor has a question about which would be the best diagnostic test to order given the specifics of Ms. Hanh’s history. He consults the hospital’s digital library, and with several mouse clicks he confirms that a computer-assisted tomography (CAT) scan is still the expert-recommended choice. He orders the study via the computerized physician order entry (CPOE) system and also orders some pain-relieving medication. The program alerts him that his medicine choice could have a dangerous interaction with one of the medications Ms. Hanh is taking. The computer suggests an alternative, which the doctor selects instead.

A few moments later, Dr. Duc sees that the patient is not in her room. He looks at the electronic dashboard, which is tracking the radio frequency identification (RFID) tag on Ms. Hanh’s wristband. He learns that the patient is transported to radiology 5 minutes ago and is currently undergoing the scan. Shortly thereafter, an alert on the dashboard warns him that the radiologist has reported an abnormality on the study. Luckily, the pain is being caused by a 'gall bladder' stone instead of something more serious. With a single click the emergency physician is able to view the digital images and confirm the findings.

Looking for assistance in managing Ms. Hanh’s gall bladder stone, Dr. Duc pages an Laparoscopic GI surgeon. Instead of wasting time waiting by the phone, he immediately goes to see another patient. He knows that whenever Surgeon call is returned, it will be routed to the digital communication device he wears on his collar. Dr. Duc generates the documentation for the patient’s ED visit through a wireless dictation or wireless tablet system that allows him to note historical and physical findings, order laboratory tests and radiographs, and submit orders via CPOE with integrated decision support system. In either case, he does not have to search for a chart or wait for someone else to finish using it.

The dashboard is updated with Hanh’s pending discharge so the housekeeping manager can ensure that the resources required to clean the room will be available when needed. The triage nurse in the ED will select the next patient to use the room when it becomes available.

A short time later, Ms. Hanh is feeling better and is ready to be discharged home. She receives a computer-generated instruction sheet with information about her diagnosis of a gall bladder stone, including what warning signs to watch for, as well as whom to follow up with and when. Upon discharge, the system sends the patient’s primary care physician, Dr. David, and the consulting Surgeon a secure e-mail summarizing the ED visit and the patient’s discharge instructions. The e-prescribing module, having screened for potential drug interactions and provided dosage guidance, electronically routes Ms. Hanh’s prescriptions to the pharmacy near her home, saving time and reducing the risk of errors associated with legibility problems.

Ms. Hanh uses her secure doctor-patient messaging application to communicate with Dr. David two (02) days later, letting him know that she was booked for laparoscopic cholecystectomy (gall bladder removal) operation with the surgeon and is feeling much better. She also mentions how satisfied she was with her emergency visit. Even though the ED seemed to be incredibly busy, everything went smoothly and efficiently, and she feels she got proper attention and great personalized care.

Although Ms. Hanh’s visit to the ED sounds like futuristic, but all technologies described in the above story are available today as both home-built and commercial products. Only the diffusion and integration of these technologies to date has been limited. The typical community hospitals and even some large medical centers are lack of basic information technology (IT) enhancements that have been shown to improve the efficiency of care and patient flow, inform clinical decision making, and enhance provider-to-provider and provider-to-patient communications.

However, this secure communication system will be more robust in future and patient will get more and more personalized care. But till then, healthcare providers should concentrate enough time to make sure the communication is effective and perfect.

It’s may take more time to human-human interaction and effective communication in each touch point but to prevent harm, this is required.