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Grand Rounds 11/02/16 @ BID-Needham: Gretchen Ruoff MPH and Maggie Janes JD  

Can We Talk? Analysis of MPL Claims Where Communication Failures Contributed to Medical Error and Patient Harm
Last Updated: Dec 5, 2016 URL: http://bidmc.libguides.com/Ruoff/Janes/2016 Print Guide RSS Updates
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Speaker: Date: Topic

Gretchen Ruoff, MPH, CPHRM

Maggie Janes, JD, BSN, RN

Nov. 2, 2016

Can We Talk? Analysis of MPL Claims Where Communication Failures Contributed to Medical Error and Patient Harm

      

    Objectives of the Presentation

    Participants should be able to:

    • Explain the breadth/impact of communication issues in malpractice cases.
    • Discuss specific examples of how communication failures lead to patient harm.
    • Define specific strategies for addressing specific communication issues.
        

      Responsibility for Content

      The PowerPoint presentation, Take-Away points, Objectives, and Disclosures were sent by Medical Library Services and the CME Committee.

      Diane E. Young, Information Specialist

      dyoung3@bidmc.harvard.edu

       

          

        Take-Away Points of the Presentation

        Information is the currency of safe care, and communication is the vehicle by which that currency is transferred. Safe care hinges on the successful gathering and transfer of information among providers, and between providers and their patients and families. Incorrect or absent information at crucial points in the diagnostic or treatment process can result in serious patient harm.

        In a recent study of over 23,000 malpractice claims (CRICO 2009-2013) communication was a factor in 30% of the cases.

        There were 3 key communication failure types:

              No exchange of information.

              Incorrect or incomplete information exchanged.

              Information is exchanged but misinterpreted or misunderstood.

        Communication failures were fairly evenly distributed between those occurring among providers within the care team AND between providers, patients and families.

        Over 50% of the cases studied occurred in four key services areas: Surgery, General Medicine, Nursing, and Obstetrics.

        The problem is serious (44% of those cases resulted in serious harm including death), prevalent (distributed evenly across inpatient and ambulatory settings), and multifactorial (driving factors and circumstances varying significantly across service areas).

        Cases involving provider-provider communication failures are more likely to result in indemnity payments (and result in greater payouts) than those with communication failures between providers, patients, and family members.

            
           

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          Disclosures

          Director of Medical Education and Committee Members have indicated they have no relevant financial interests or relationships to disclose. Faculty has indicated no relevant financial interests or relationships to disclose.

              

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