Communication Breakdowns in the Emergency Department as a Source of Malpractice

It is well-known that medical errors are common across the Unites States healthcare system. Many of these errors can lead to significant harm to patients. The unique clinical environment of the emergency department (ED) makes it an area that is particularly prone to medical errors. This can lead to serious adverse events. Many factors contribute to this unique environment; the time pressures faced by physicians and nurses, the large number of decisions that must be made with limited clinical information, the 24-hour nature of the ED that forces providers to work against their circadian rhythms, the frequent interruptions, the discontinuity of care caused by recurrent sign-outs, and the high acuity (the intensity of care needed) of the patients, to name just a few.

In a study published in 2003, the most common type of error observed in the ED was related to diagnostic studies, followed by medication-related issues. Both of these are worthy of note. However, one of the common, and preventable, sources of medical errors in the ED as revealed by this report is communication breakdown. In the fast paced environment of the emergency department, there are many scenarios where communication breakdown can occur. This leads to patient harm and the potential for malpractice claims. In this article, we will focus on the communication between patient and provider at the time of discharge and use a case example to illustrate potential communication failures. The communication of after-visit instructions, if done well, is critical to preventing adverse events and medical malpractice.

Source: Fordyce et al. Ann Emerg Med. 2003;42:324-333

Patient-Provider Communication

Effective communication between patients and providers is an absolutely essential ingredient of sound clinical care. This communication occurs during four general phases:

1. First, communication between the patient and the triage nurse influences where and how quickly the patient will be evaluated.
2. Second, communication between the clinician and patient regarding the presenting symptoms and medical history will directly guide the diagnostic process.
3. Third, the clinician will relay information regarding test results and any diagnoses that have been made.
4. Finally, the clinician must effectively communicate after-visit instructions so that the patient understands what to do after leaving the ED.

There are three main components to the after-visit instructions:

1. Follow-up, i.e. when and with whom will the patient obtain subsequent care.
2. Treatment, i.e. what therapy is required after leaving the ED.
3. Return Precautions, i.e. what symptoms to monitor for that would necessitate an immediate return to the ED.

These after-visit instructions are typically delivered via two modalities. First verbally, by the discharging provider and, second, often with printed discharge instructions. For this communication to be successful it should be delivered in a manner and language that is understandable to the patient. Specially, this means that medical jargon should not be used; rather, simple, lay language should be used whenever feasible.

For example, a provider should not instruct a patient to “Please return to the ED if the erythema or edema progress”. A more understandable way to express this to a lay patient would be, “Please come back here to the emergency room if you see the redness or swelling get worse”. In addition, clinicians should avoid using medical terms and acronyms when communicating a diagnosis to a patient. Similarly, a “blood clot in your leg” is much easier for a typical patient to understand than a “lower extremity DVT”.

For return precautions to be useful, they should be precise and specific to the condition of the patient. For example, instructing a patient with abdominal pain to “come back if they feel worse” is much less useful than instructing them to “come back if you have fever or if your pain moves to the right lower part of your abdomen”. Patients in the ED are often in pain or feeling anxious, which can in turn lead to decreased cognition. Therefore, clinicians should make every attempt to explain things in a simple manner and confirm understanding by asking patients to repeat the after-visit instructions back to them.

Finally, after-visit information should be delivered in a language that both the patient and clinician are fluent in. In the event of language discordance, a trained medical translator should be used, when possible. Written discharge instructions should also be given in a language that the patient can read when possible. Neglecting to provide clear, understandable, and specific after-care instructions can lead to a poor clinical outcome for a patient. It could also constitute a breach in the standard of care.

Case Example

A 48-year-old Hispanic man presented to the ED after a high-speed motor vehicle collision. He sustained soft tissue injuries to his entire right arm and a small fracture of the right wrist (non-operative). After a period of observation, he was placed in a right sugar-tong splint and discharged with pain medication. He was told to follow-up with an orthopedic surgeon in 10 days. While the patient spoke only Spanish, his discharge instructions were provided only in English.

Furthermore, the return precautions were generic, instructing him to contact his physician if he had “problems that concern you… pain, bleeding, nausea, signs of infection…” There was no documentation of a verbal communication of specific return precautions, given in Spanish, regarding the care of a sugar-tong splint and a fractured wrist. The patient kept the sugar-tong splint on until he followed-up 10 days after discharge. By that time, he had developed pressure necrosis to the entire wrist and forearm. He required multiple procedures, including a skin graft. Had the patient been given specific return precautions, in a language he could understand, and more rapid follow-up, this harm would likely have been prevented.

The emergency department contains several inherent characteristics that make it prone to medical errors. These errors can lead to serious patient harm, and the root cause of these medical errors is often a breakdown in communication. Effective communication between the patient and the clinician, especially at discharge, is critical to preventing adverse outcomes and thus medico-legal action.

Attorneys reviewing medical malpractices cases of patients who were discharged from the ED should carefully review the documentation surrounding the discharge to evaluate the adequacy of these instructions. Three elements of the after-visit care should be considered: Were the follow-up plan, treatment instructions, and return precautions effectively communicated in a manner and language that were understandable to the patient? Being mindful of these simple actions will lead to better medical care and improved safety for both patients and clinicians.