6 Communication Tips to Reduce Medical Malpractice Risk

Boarding Patients: While the patient is boarding in the ER, waiting for their hospital bed – Who is the attending physician? Who takes care of a decompensating boarding patient? – Hospitalist or ER doc? Pending workup–ER doctors calling for an admission while workup is still pending. Pending labs or images might determine the need for another service/consultant to be involved.

Calling Consults: ER doctor says “I spoke to cardiology.” Was cardiology officially consulted?, was it a curbside?, was an EHR order placed? Does the hospitalist need to call the consultant again?

Patient Transfers: Confusion regarding services that may not be available at the hospital (Ex. Liver Transplant services not available at the hospital. Transfer patient to a tertiary care center vs. Keeping patient in house. What if a particular sub-specialty is not available at the hospital? Does the ER doctor push an admit to hospitalist, or will they transfer the patient?

Attending Physician: If patient needs multiple specialists, who assumes the attending role?

ER Team Shift Changes: ER hand-offs are important to eventually improve the quality of hand-offs to the admitting physicians.

Who Call Consults? The RN or the Attending physician.

Phone Orders: Does the RN place orders in the computer after receiving verbal orders or text orders? Read back protocols when verbal orders are placed.

Communication Platform Standards: Lay out the rules of communication–pager vs. call vs. overhead announcement vs. text, etc. When do you use a particular form of communication?

Communication Structure: SBAR (Situation, Background, Assessment, Recommendation) is a proven and effective system. Do you use this structure while communicating with other healthcare team members?

Hand-offs Are Mandatory: Do you have a standardized written form of hand-offs when you leave your shift? (e.g. Pending labs, Pending consults)

Pending Test Follow-Ups: Who follow-ups on a test ordered by a physician that is about to go off-service. There is a traditional medical saying – “if you ordered it, you own it.” So make sure you appropriately hand-off these pending labs or tests to the incoming physicians, so you don’t land in legal trouble.

Documentation Cannot be More Important: Make sure to document everything you do. It is probably the most extensively used mode of communication among physicians. Another famous saying–“if it is not in the chart, it did not occur.” Documentation can your best asset or worst enemy when it comes to legal issues.  Do a thorough job documenting all you do, and this will be become the basis of claims defense.

Inpatient and Outpatient Physicians: A well-established communication portal must be developed to enable clear communications between inpatient and outpatient physicians. Inpatient physicians can inform outpatient physicians about pending labs, consults, and the next steps of follow-up and medical management after a complicated hospital stay.

Importance of Setting Expectations: Letting patients and their families know regarding roles of various treatment teams and/or consultants, sharing practical expectations of recovery and time frame.

Keeping Patients’ Family/POA (Power of Attorney) in the Loop: For patients who are unable to communicate effectively, their respective POAs must be given regular updates, either by you, or an RN or someone who knows the current treatment plan. Have an established process for this.

Communication: Communicate with patient regarding new medication at discharge, changes to prior medication, follow-ups with physicians.

Follow-Ups: Who sets up the follow up appointment? Do the patients have to call a phone number to make an appointment? Does the physician’s office call the patient? Having a clarity in this topic is vital.

Written Instructions: A detailed print out of instructions must be given to patients regarding final medical reconciliation, and all other discharge recommendations–wound care, activity status, and dietary recommendations. If you are recommending a low sodium diet and extensive education, written instructions must be provided to patients regarding what this means.

Being a Liaison: Physicians are on the front line on healthcare delivery. We are usually the first ones to notice any inefficiencies. It is our responsibility to liaison with the hospital administrator or leadership to take up these issues.

Protocols and Processes: At the end of the day, process changes must be made to improve outcomes, and hospital leadership plays a vital role in establishing a ‘Swiss Cheese Model’.

Swiss Cheese Model: When an unfavorable patient care event occurs, it can be noted that the event could potentially be avoided or nullified at several checkpoints. A well-known example of the Swiss Cheese Model is still valid in this topic. When these multiple checkpoints fail to capture the error, all the holes in the Swiss Cheese lineup, leads to unfavorable outcomes. This topic highlights the need for system based approach to mitigate unwanted outcomes. A comprehensive approach must be followed, involving a multi-disciplinary approach to lay out all the possible error-prone areas, hold discussions in a non-judgmental environment, and come out with changes that have the efficiency to prevent errors, and detect errors at an early stage, much before they can influence an outcome.

(ex. If the patient received the wrong medication in the hospital, resulting in an adverse effect, there are several potential checkpoints that should be evaluated–physician knowledge deficit, negligence, fatigue from overwork, communication error, EMR technological issues, documentation errors, pharmacy review, telephone order inefficiency, and etc.)