Miscommunication A Major Cause of Medical Error, Study Shows

By Irene Noguchi

It seems almost unbelievable, but medical errors may be the third leading cause of death in America, after heart disease and cancer. That's according to an analysis from Journal of Patient Safety. Could the key to change be in better communication? A new study from UC San Francisco and eight other institutions, says yes. Researchers found that improving communication between health providers can reduce patient injuries from medical errors by 30 percent.

The team found that a highly risky period was when patients are transferred or “handed off” between medical providers. Critical information gets passed between doctors, nurses and pharmacists.

When there’s a shift change or a patient moves to another hospital, “there’s an opportunity for communication failure,” says Daniel West, professor of pediatrics and vice-chair at UCSF Benioff Children's Hospital.

“When there’s a breakdown in communication, it sets the stage for potential errors,” West said recently on KQED’s Forum. Those errors can lead to upwards of 1,000 deaths per day and cost trillions of dollars in health care costs each year.

Dr. West says there is no national standard for health care [health care is two words/AP style_] providers to follow when it comes to improving that handoff of information.

“Usually people learn on the job, what we call a ‘hidden curriculum,’” West says, where information is passed by word-of-mouth among colleagues. He wants to standardize that education with a set curriculum. Dr. West estimates that more than $1.5 billion in savings annually if every U.S. hospital adopted that curriculum.

Still, it’s hard to determine the exact number of deaths due to medical errors. In 1999, the Institute of Medicine stunned the public when it reported that 98,000 people per year died from hospital mistakes. Last year, in its study, the Journal of Patient Safety found that rate was much higher --  between 210,000 and 440,000 patients suffer some preventable harm that leads to death, researchers found. The numbers vary widely, partly due to reticence in the medical community to report a colleague’s mistakes.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation and a professor at Harvard, admits that’s largely due to what she called the “closed door” culture of hospitals. “[We should be] creating a culture where people feel comfortable talking about errors and not feeling they’re going to be fired,” she says. "We need better systems than simply relying on reporting.”

California has laws pertaining to mistakes. Health care professionals are required to report errors to the Department of Public Health, and there are $100-per-day fines for non-reporting. “Laws and regulations can really incentivize people to do things differently,” says Betsy Imholz, an expert on health policy for Consumers Union.. But she admits enforcing those laws is “complicated. There isn’t one silver bullet for it.”

“Doctors don’t want to do badly, they go into the work to heal people,” Imholz says. But public exposure and transparency “can improve things as well.”