Communication Failures and Malpractice: How Structured Handoff Tools Can Improve Patient Safety

Tool: I-PASS

Problem: According to the Joint Commission, miscommunication as a leading cause of sentinel events. We sought to determine the proportion of medical-malpractice claims involving communication failure and describe their nature, including providers, locations, miscommunication types, costs, and potential for handoff tools to avert risk and associated costs.

Tool Selection: I-PASS implementation has been demonstrated in multiple prior studies to reduce medical errors. We sought to understand what impact I-PASS might have on rates of malpractice claims and associated costs.

Usage: We conducted a retrospective study of 500 randomly selected claims from a national database. Each claim was reviewed by physicians who determined if a miscommunication was involved, costs of the claim, and the potential role of I-PASS in averting a claim.Results:49% of claims involved miscommunications. Claims involving miscommunications were much more expensive than those that did not ($238,000 versus $154,000). I-PASS could have prevented a majority of those claims involving a failed handoff.

Speakers
Chief of General Pediatrics, Director of the Sleep and Patient Safety Program, William Berenberg Professor of Pediatrics
Chief of General Pediatrics, Director of the Sleep and Patient Safety Program, William Berenberg Professor of Pediatrics – Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School

Speaker Type: 60 Minute Session On-Demand

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Associate Medical Director for Patient Safety
Associate Medical Director for Patient Safety – Boston Children’s Hospital

Speaker Type: 60 Minute Session On-Demand

  • Performance and Process Improvement IconPerformance and Process Improvement
  • Patient Safety IconPatient Safety
Event Details