Malpractice Threats in Well-Intended Patient Handoffs


Life-changing errors in the patient handoff from one doctor to another are becoming more frequent, and they are increasingly occurring among doctors with good intentions who think they’re providing fine care.

Some insurers say they’ve noticed a disturbing spike in the number of lawsuits stemming from avoidable failures when patients are transferred or handed off. The exact increase is difficult to quantify because malpractice cases take years to work through the legal system.

“It’s rare for there to be only one physician who follows a patient through the entire course of treatment,” said Alan Lembitz, MD, vice president of COPIC, a professional liability carrier based in Denver, Colorado. “Almost all claims have multiple defendants and points of contact.”

The potential for mishaps rises dramatically because of the increasing fragmentation in medicine. “The patient’s primary doctor may admit him, or maybe it’s the emergency department physician,” said Dr. Lembitz. “Then he may be seen by 3 or 4 hospitalists and a couple of specialists. Who will handle needed follow-up often isn’t clear.” When shifts change in hospitals, when one doctor refers the patient to another, and when patients are discharged, vital information often falls between the cracks.

An estimated 80% of serious medical errors involve miscommunication between caregivers when patients are handed off, resulting in severe patient injury or death, delays in treatment, and increased length of stay at the hospital, the Joint Commission’s Center for Transforming Healthcare said earlier this year when it released a new program [1] to help fix the broken communication process.

The Problem Is Extensive

Direct communication between hospitalists and primary care physicians is rare, happening only 3%-20% of the time, according to a 2007 study published in JAMA. [2] A majority of hospitalized patients are unable to name their doctor, [3] and a majority of discharge summaries don’t highlight tests and studies that are pending. [4]

“There are 4000 handoffs a day in a typical teaching hospital,” Joint Commission President Dr. Mark Chassin said. “If 90% go flawlessly, that’s still 400 failures per day.”

There’s a huge disconnect in how “sending” and “receiving” doctors perceive what each is doing — or should be doing.

For example, a 2011 study in Archives of Internal Medicine found that 69% of primary care physicians reported sending patients’ histories to specialists all or most of the time. Yet, only 35% of specialists said they routinely receive the information. Whereas 81% of specialists reported sending their results to the referring physician all or most of the time, only 62% of primary care physicians report receiving the information. [5]

Hospitalists expect that primary care physicians should relay all the previous laboratory and radiographic data that were available. A phone call would be even better, said Dr. Lembitz. “And the primary care doctor is thinking, ‘It would be nice if the hospitalist called me back after seeing my patient so that we could actually discuss this case.'”

The classic fumble in the patient handoff is when the specialist thinks the primary care doctor is going to take care of some aspect of follow-up, and the primary care doctor thinks the specialist is handling it.

Malpractice insurers that we interviewed gave these examples of handoff errors:

A 38-year-old woman detected a lump in her breast and was referred by her primary care physician to a surgeon. The surgeon found no mass, but recommended that she be reexamined in 1 month. Each physician assumed that the other would follow-up, Dr. Lembitz said. Nine months later, the patient returned to her doctor with a larger mass and was diagnosed with breast cancer.

A healthy newborn boy was treated by a neonatologist within the first 12 hours of his life. Although a bilirubin test was ordered, the covering neonatologist discharged the child within 24 hours, unaware of the laboratory results. At 60 hours, the baby was seen by a pediatrician at an ambulatory care center; a bilirubin test was again ordered before that doctor left for vacation, expecting that the laboratory would contact the parents and her call coverage physician.

The covering pediatrician (from a different group practice) didn’t have accurate contact information for the mother. The next day, when the regular pediatrician saw the fax from the laboratory, he contacted the mother and asked that the baby get to the hospital as soon as possible.

The patient was admitted at 77 hours but died of kernicterus, a preventable disease if had it been recognized on the basis of the 2 previous laboratory results. The bilirubin level was 16 mg/dL at 12 hours of age, 32 mg/dL at 60 hours of age, and 44 mg/dL on admission at 77 hours.

A test result requiring immediate action was called to a night doctor, “who not only did nothing, but also failed to tell the day doctor about it,” said Stella Fitzgibbons, MD, a hospitalist in Houston, Texas, who reviews malpractice cases. “That day doctor, for his part, was ‘just filling in’ and left the problem for the ‘regular doctor’ to deal with, causing expensive and irreversible problems for the patient.”

A 61-year-old woman was hospitalized with abdominal pain. A lesion was found in her spleen. Resection revealed an abscess with methicillin-resistant Staphylococcus aureus. An infectious disease specialist recommended a 4-week course of vancomycin.

One week later, the patient was transferred to a rehabilitation facility. An echocardiogram had shown subacute endocarditis, but the report on it was not returned until after discharge and was neither seen by nor relayed to the subsequent providers.

The patient’s nonhospital physician assistant had no records on this finding and was not sure why she was still receiving vancomycin. He stopped the medication 1 week later, especially because maintaining intravenous access was difficult for this patient. Two more weeks after the medication was stopped, the patient presented with a spinal abscess and paralysis — the result of a failure to transmit critical information.

“We’re seeing the same patterns of claims over and over again,” said Dr. Lembitz. “The inconsistent or incomplete handoff is what leads to the problem.”

Malpractice Threats in Well-Intended Patient Handoffs.  Medscape. Oct 04, 2012.