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One hospital's experience suggests that communication problems may underlie a substantial number of hospital adverse events

Hospitals make every effort to avoid adverse events (AEs), that is, harm or injury to a patient due to health care. A study supported in part by the Agency for Healthcare Research and Quality (HS11563) highlights the importance of good communication in preventing AEs.

Investigators from the Vanderbilt University School of Medicine analyzed risk management files from one urban hospital's department of obstetrics and gynecology to identify factors that may have contributed to or caused unanticipated AEs. They categorized 90 AE cases into three department service areas: gynecologic surgery, inpatient obstetrics, and outpatient clinic. AEs ranged from operative injury and postoperative complications, to missed diagnosis, inadequate treatment or monitoring, and inappropriate medication.

Communication failures (disrupted flow of critical information from caregiver to caregiver or between patient and caregiver) were associated with 31 percent (28 cases) of AEs. In 19 of these cases, communication failures appeared to contribute directly to the AE. Also, communication failures may have worsened 7 of the 28 cases involving surgery or treatment errors and 5 of the 16 cases involving diagnostic errors. Clinical performance issues contributed to 31 percent of adverse events; diagnostic issues, 18 percent; and patient behavior (for example, substance abuse or treatment noncompliance), 14 percent. Although these findings are not generalizable to other hospitals, the researchers suggest that review of risk management files may help uncover system problems that are unique to other hospitals.

More details are in "Cause and effect analysis of closed claims in obstetrics and gynecology," by Andrew A. White, M.D., James W. Pichert, Ph.D., Sandra H. Bledsoe, R.N., A.R.M., and others, in the May 2005 Obstetrics & Gynecology 105(5), pp. 1031-1038.

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