Good Patient Communication May Prevent Medical Errors

Good Patient Communication May Prevent Medical Errors

A Call to Arms

When the Institute of Medicine published “To Err is Human: Building a Better Health System,” which blamed America’s health care system for 44,000 to 98,000 error-related deaths annually, many physicians questioned the report’s data. Office-based physicians especially questioned the report’s focus on inpatient care. Whether there are problems with the data or not, the report still exposed serious and preventable errors in our health care system, specifically with inpatient care. If office- or clinic-based physicians view the report as a call to arms, they may not have to read a similar report about outpatient care. The Institute’s report recommends improving communication among teams. Patients are essential members of health care teams, and communications with patients—in the hospital, in the office, and in the clinic—require consideration.

It’s Not Just an Inpatient Problem

Most physicians—in any setting—are at risk for communication errors because virtually every physician conducts patient interviews. Dr. Mack Lipkin, one of the editors of The Medical Interview, says the patient interview is a fundamental clinical skill for all health care providers. The Medical Interview reports that primary care physicians conduct between 12,000 and 160,000 interviews during a 40-year career. Whether practicing in a hospital, office, clinic, or even a research lab, communicating with patients is inevitable.

Communication in health care is not limited to the physician-patient relationship. Patients talk with and receive written information from secretaries, nurses, and laboratory personnel. Physicians and other health care providers document information in patient medical records and discuss patients with each other. Patient information is passed from one provider to another via telephone, facsimile, electronic mail, letters, consultation notes, laboratory reports, etc. There are countless opportunities for good communication, but also plenty of chances for poor communication.

In 2002, the California Academy of Family Physicians studied 330 errors in outpatient settings reported by 50 physicians during one year. The CaliforniaAcademy used the AmericanAcademy of Family Physicians definition of “error,” which included anything that happened in the physician’s office that should not have happened and that the physician absolutely does not want to occur again. Notably, almost one quarter of the errors were due to communication problems between physicians and patients and between physicians and nursing staff.

The AmericanAcademy of Family Physicians published a similar study in 2002 entitled “A Preliminary Taxonomy of Medical Errors in Family Practice.” The Academy looked at 344 reports by 42 physicians and found six percent of errors were caused by “miscommunication.” While miscommunication in this study did not appear to be a significant source of errors, Dr. Susan Dovey, one of the study leaders, said many of the errors appeared trivial on the surface but had serious consequences. One death was linked to a mismanaged message. In another reported error, the patient’s biopsy was positive for melanoma, but the report did not contain any contact information resulting in a lack of communication to the patient. This study indicates the severity of communication errors with patients and staff may be greater than the actual frequency of communication errors.

HIPAA Has Complicated Matters

The November/December 2003 issue of HIPAA Regulatory Alert advises that attempts to comply with HIPAA may actually impede health care communication. For example, some hospitals have stopped putting names on patient boards at nursing stations and have replaced names with initials or symbols making it harder for physicians to find a patient. An extreme example is the hospital that replaced patient names on identification wrist bands with bar codes. Another example is a pathologist’s office who refused to provide a lab result to the referring dermatologist’s office without the patient’s written authorization. Medical clinics and offices must strive to comply with HIPAA and state laws and regulations without impeding communication or delaying patient care.

Nonverbal Communication and Patient Outcomes

Nonverbal communication also plays an important role in physician-patient communications. A study published in the January-February 2002 Journal of the Board of Family Physicians entitled “Physician-Patient Communication in the Primary Care Office: A Systematic Review” cites sixteen nonverbal behaviors associated with patient outcomes, include head nodding, leaning forward, direct body orientation, uncrossed legs and arms, and symmetrical arm movements/position. Behaviors associated with unfavorable outcomes include body orientation 45-90 degrees away from the patient or indirect body orientation, leaning backward, crossed arms, and frequent touching.

Additionally, in her chapter on nonverbal communication in Conversations in Care, Improving Healthcare through Better Physician/Patient Communications, Dr. Debra Roter offers these tips for communication with patients:

Offer patients a firm handshake and a warm greeting.
Sit down when talking. If you must sit behind a desk, place the patient’s and/or family member’s chairs to the side of your desk.
Maintain eye contact for 80 percent of the visit.
Turn toward the patient and lean forward.
Avoid crossing your arms and legs.
If standing, avoid shifting your weight from side to side.
Avoid sighing, yawning, and rolling your eyes.

Two Little Words

Lastly, Mayo Clinic Proceedings looked at patient interviews and compared physicians’ interview techniques with the level of patient disclosure. The title of the study, “Two Words to Improve Physician-Patient Communications: What Else?” emphasizes a key finding: many doctors learn about the patient’s true chief complaint at the end of a visit. The study found that the use of “continuers,” expressions that allow the patient to reveal all of his/her concerns, may encourage patients to express their true chief complaint sooner. Examples of “continuers” may include asking patients “What else?” and “Anything else?” Studies show that it only takes 150 seconds for patients to express all their concerns. Two-and-a-half minutes spent with a patient may be time well spent in avoiding medical errors and preventing medical malpractice claims.

10 Most Common Errors When Communicating with Patients

In 2003, the Institute for Healthcare Advancement issued a list of the ten most common errors health care providers make when communicating with patients:

Using brochures and other literature to explain how to take medications which are written at an eleventh grade reading level when the majority of Americans read at a sixth-grade reading level.
Using medical jargon when simpler words would suffice. For example, saying “otitis media” instead of “ear infection.”
Using a font size that is much too small for senior citizens (the largest patient population) to read.
Not asking patients to repeat back verbal instructions.
Not recognizing that 30 percent of Americans read at a third to fifth grade reading level yet most reading materials are written at an eleventh grade reading level.
Many patients nod or answer “yes” to be polite, but they do not actually understand what has been said.
Displaying and distributing mass-produced brochures and other literature that has not been read or checked by the physicians and staff to ensure the information is current and in line with office or clinic policies and recommendations.
Talking too quickly and not allowing patients time to ask questions.
Not providing information in the patient’s first language.
Using ambiguous language when writing prescriptions and giving directions. For example, writing, “Take with food,” when the proper is, “Take on a full stomach after a meal.”