In nearly 1 in 5 adverse drug events in hospitalised patients, relevant patient information was missing1. Similarly, in 1 in 6 errors of all types in general practice missing information contributes2.
Information that had previously been collected was unavailable in nearly a third of emergency department attendances, and nearly half the time that missing information was judged essential for patient care3. The figures are similar for general practice visits4, and only somewhat better in practices with well-developed Electronic Medical Records and test results tracking systems5.
Potential for harm is increased when valuable consulting time is spent trying to retrieve important data4.
Practice PointAt the time a faulty decision was taken, the disregarded information may have been unavailable. |
Communication failures among care-givers and between care-giver and patient are an ever-present source of potential medical error.
In hospital care, communication problems are endemic between doctors and nurses6,7,8, general and specialist physicians9,10, attending physicians and residents11, pediatric patients and parents and physicians12. Interpersonal difficulties and conflicts are a major source of communication failure in hospital13.
About 8% of general practice outpatients suffered adverse drug events that would have been ameliorated if either the physician had responded to symptoms reported by the patient or the patient had reported symptoms to the physician14.
General practitioners and specialists agree that referral letters should minimally include a statement of the problem, details of current medication and reason for referral15. Omissions of such important details are common and may result in serious error16.
Predictably, quality of referral information determines quality of written feedback from the consultant17.
Practice PointCommon substandard deficiencies in referral letters from general practitioners to specialists:
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Information gaps accumulate and trigger medical mistakes that are not infrequently serious, sometimes lethal.
The Australian Health Care Study found that communication problems were the most common cause of preventable disability or death18.
Information gaps are common and to some extent inevitable19, []. They are an ever-present source of latent errors that combine to cause the most blatant and publicised medical mistakes, such as wrong patient, wrong limb, wrong drug20, [].
In the dynamic and rapidly changing environment of clinical practice, beefing up information management systems will never be sufficient. As is successfully achieved in the aerospace and aviation industries, highly redundant mandatory error detection systems must be integrated. Lack of such fail-safe support for health-care professionals arguably constitutes systemic negligence.
Copyright © 2009 Electronic Handbook of Legal Medicine