Closing the Gap on Medical Errors & Communication Failures that Lead to Suboptimal Patient Care

Closing the Gap on Medical Errors & Communication Failures that Lead to Suboptimal Patient Care

By: William J. Maples, M.D. and Diane L. Colgan, M.D., F.A.C.S.

A recent article, “Physician Burnout May Lead to Suboptimal Patient Care[1]” documents physicians experiencing burnout were more likely to have patient safety incidents, poorer quality of care, and reduced patient satisfaction. The Joint Commission estimates that miscommunication among medical staff while transferring patients from one provider to another contributed to 80 percent of serious medical errors[2]. How do we move the needle in medical errors and miscommunication to better serve patients and help save lives?

Medical errors, including wrong diagnoses, surgical mishaps and medication mistakes, are the third leading cause of death in the United States, a new study suggests. Scientists from Johns Hopkins found that more than 250,000 Americans die due to medical mishaps every year, greater than the toll from any major medical condition except heart disease or cancer[3].

“Up to 50 percent of preventable medical errors are related to a breakdown in communication,” says Dr. William Maples, President and Chief Executive Officer of The Institute for Healthcare Excellence (IHE). “The key to decreasing preventable medical errors is to build a culture of safety which is rooted in effective, authentic, and compassionate communication. As the complexity of medicine increases, there is a greater need for teams to work effectively together with the patient at the center of the team to maximize outcomes and safety. This requires a culture of trust where every member of the team feels safe to share what he/she is observing as the team navigates through a care pathway. At the root of building this trust is effective, open, honest, and authentic communication between all members of the team.”

It is imperative that healthcare leaders, physicians, nurses, and support staff realize the strong interdependence between creating a culture of patient-centered, team-based, and compassionate care with the delivery of exceptional clinical safety, outcomes, and efficiency. Implementing the skills of the RELATIONS® for Healthcare Transformation program including presence, reflective listening, accurate and efficient information gathering, joint agenda setting, recognizing emotion and responding appropriately, and appreciation is critical to understand what patients, families, and colleagues need and want. “I was taught to just listen to the patient for an uninterrupted few minutes and they will tell you what is wrong with them or at least give you a differential diagnosis.  Within those few minutes you have made a vital connection and created a safe place for that patient.  It also saves time and virtually eliminates the need to go through an extensive laundry list of questions. The patient knows you care and that they will be your partner in decisions related to care. In addition to nurturing a culture of excellence rooted in teamwork, trust, and compassion, maintaining the physical, mental, and spiritual well-being of the clinician is vital. Integral to safe, quality care is a healthy clinician,” says Dr. Diane Colgan, Chair, Medical Staff Leadership Council at Suburban Hospital/Johns Hopkins Medicine and IHE faculty member.

Clinician burnout has several detrimental consequences, including endangering patient safety, low productivity, and loss of coordination of care. Addressing intimidation, harassment and bullying in clinicians by encouraging open communication, and creating a blame free environment for reporting errors are important steps to promoting a culture of excellence and safety.

The Institute for Healthcare Excellence provides an opportunity for physicians, nurses, and support staff to develop necessary skills to create a culture of excellence rooted in respect, trust, and compassion.  This culture will ensure delivery of exceptional care with an exceptional experience for patients, families, and the caregiver team.



The Institute for Healthcare Excellence partners with healthcare organizations to nurture relational skills necessary to create a culture that embraces trust, respect, compassion, and teamwork – creating an environment where quality, safety, and efficiency can flourish. Through this work, physicians, nurses, and the caregiver team reconnect to purpose and restore joy to the practice of medicine. The result of the culture-transforming work is a restoration of humanity to medicine.




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