The Pharmaceutical Journal
Vol 273 No 7311 p179
7 August 2004

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Miscommunication key culprit in medical errors

Diagnostic and treatment errors often begin with a communication problem, say US researchers in an analysis of medical errors.

The group looked at 75 error reports from family doctors. They traced back the errors along a string of events by using cascade analysis. They found that two out of every three mistakes were set in motion by miscommunication. In 7 per cent of cases, a pharmacy was implicated in the reported error.

Examples of errors included the wrong laboratory report attached to a patient’s letter, delaying treatment of hyperlipidaemia.

Communication breakdown among colleagues was common (44 per cent). Of these, 20 per cent of errors involved misinformation in the medical record and 12 per cent involved inaccessible records. Some 18 per cent of errors involved mishandling of patients’ requests and messages and 5 per cent were caused by inadequate reminder systems.

The authors suggest that safety initiatives should focus more on management systems to enhance the quality of information transfer.

The authors found that patients were more likely to report an error in terms of psychological and emotional harm than actual physical harm. Doctors, on the other hand, were more likely to report physical harm and less likely to report the emotional effects of an error (Annals of Family Medicine 2004;2:317).

Another US study looked at the types and importance of medical errors in primary care. Again, patients’ perceptions of problems involved psychological and emotional issues rather than technical errors.

Over 200 problematic incidents in primary health care were identified from 38 interviews with adults. The incidents were found to involve breakdowns in the doctor-patient relationship (37 per cent), entailing disrespect or insensitivity to the patient. Another major problem was access to clinicians (29 per cent of events).

Misdiagnosis or adverse drug events (23 per cent) were reported less frequently than difficulties with relationships and access (ibid 2004;2:333).