Physician Errors During Patient Handoffs Lead to Liability Claims

i-physicianerrorsduringpatientMedical errors that occur while shifting a patient from one physician’s care to another has sparked an increase in medical malpractice claims over the last five years, according to Alan Lembitz, MD, vice president of COPIC, a Denver-based professional liability insurance company. Incomplete patient information, missing test results and poor communication among physicians head the list of errors, as reported in

Changing Practices and Poor Communication at Fault

The team approach to health care, including primary care physicians and numerous health care specialists, has contributed to the problem. However, most errors are the result of simple communication breakdowns. For example:

  • A 2007 study in The Journal of the American Medical Association found that direct communication between hospitals and primary care physicians is rare ─ happening only 3 to 20 percent of the time.
  • An Archives of Internal Medicine study showed that 69.3 percent of primary care physicians reported sending patients’ histories to specialists all or most of the time, but only 34.8 percent of specialists said they routinely receive the information.
  • Conversely, 80.6 percent of specialists reported sending their results to the referring physician all or most of the time. But only 62.2 percent of primary care physicians reported receiving the information.

Our firm is handling many cases where a failure in handoff communication caused serious injury and death. For example, in one case an emergency room doctor was finishing his shift and wanted to get home. His patient, however, needed a specialized CT scan which could have been completed in the ER within fifteen minutes.

Instead of doing the test, the doctor chose to hand the patient off to other doctors, but did so poorly and the CT never got done. As a result, the patient’s condition went undiagnosed for eight hours and he ended up dying. What we found out later is that the hospital had no program in place for training its personnel on how to ensure proper handoffs. Sadly, this is far more common than it should be.

Consistency, Follow-Through Key to Successful Communication

To avoid communication failures with other medical professionals, physicians should deliver information face-to-face whenever possible. When information is sent, ask the receiver to confirm receipt. Without confirmation, the physician should follow up, rather than assume successful delivery.

Standardized safety checklists can also help physicians avoid communication failures during patient hand-offs to another doctor. Checklist items include:

  • Confirm and document discharge of medication and indicate that patients understand dosage and potential
  • Confirm completion of discharge summaries and date of future tests and appointments
  • Indicate patient’s understanding of follow-up care procedures
  • Update the patient’s primary care or referring doctor on patient care
  • If possible, invite patient’s family to discuss after-care management
  • Encourage patients to make their own checklists to make sure they understand their condition, their future testing or appointment schedule and where to call with questions or concerns

If you or a loved one has been injured due to the negligence of a medical professional, contact an experienced medical malpractice attorney in your area to understand the options available to you.


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At Cirignani Heller & Harman, LLP, we represent Illinois clients in Chicago and throughout Cook County, including the cities of Cicero, Elgin, Schaumburg, Oak Park, Maywood, Berwyn, Elmhurst, Evanston, Skokie, Des Plaines, Mount Prospect, Arlington Heights, Palatine and Hoffman Estates. We also help clients in DuPage County, Kane County, Lake County, McHenry County, Will County and Winnebago County. If you have been the victim of medical malpractice in Illinois, CHH Law is the law firm with attorneys that can help.

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