Although the consequences of medical malpractice are often clear, devastating and sometimes irreparable, malpractice is not always the result of a mistake a doctor or hospital makes during treatment of disease or disorder. Sometimes, the problem lies in the communication of information, or failure to communicate.
A recent study published in JACR – Journal of the American College of Radiology – concluded that the risk of a malpractice lawsuit can increase when the notification of diagnostic test results breaks down between a referring doctor and a treating doctor.
Let’s say a primary care doctor refers a patient to a surgeon. Standard medical practice is for the surgeon, or treating physician, to ensure that the primary care doc is given the results of examinations and/or diagnostic tests if they yield an urgent or unexpected finding. And, commonly, even if they don’t. After all, a primary care doctor knows the patient best, and is considered the “gatekeeper” of a patient’s overall health-care profile and treatment.
The JACR study showed that in recent years, clinicians have ordered dramatically greater numbers of diagnostic examinations. Between 1996 and 2003, malpractice payments related to diagnoses increased by approximately 40 percent. “Communication failures, the authors said, “are a prominent cause of action in medical malpractice litigation. … [C]laims payments increased at the national level by an average of $4.7 million annually. …[C]laims data for 2004 to 2008 indicate that communication failures played a role, accounting for … 7 percent of the total cost.”
These numbers, the study suggests, might reflect the fact that people assume medical data is being reliably communicated among caregivers when sometimes it isn’t. It might reflect the remarkable growth of diagnostic testing, which generates a lot more test reports, some of which are invariably not going to be sent to every caregiver a patient sees. Whatever the reason(s), researchers concluded, “If notification reliability remained unchanged, this increased volume would predict more failed notifications.”
The researchers advise the implementation of “semiautomated critical test result management systems” to improve notification reliability, workflow, patient safety, and, in the event of a lawsuit, to provide legal documentation.
We advise that any patient who undergoes an examination or diagnostic test-X-ray, CT scan, MRI, lab work, etc.-administered by a doctor other than his or her primary caregiver request that a copy of the report and/or results be sent to the primary caregiver. And any other specialist who has participated in the patient’s care for this particular problem. Call your doctor(s) a week or 10 days after the specialist has your results to ensure they have received them.
And as always, we recommend that patients get copies of any test reports themselves. That is the ultimate preventive measure against communication failures.