Communication breakdowns can fracture your risk and patient safety efforts. Lori Duffy shares why they happen and what you can do to course-correct.
In the Top Drivers of Risk series, I explore the most common malpractice allegations and identify strategies to enhance patient safety and minimize risk.
This month, I examine communication breakdowns. At Curi, we routinely analyze our malpractice claims to identify and explore the top allegations and contributing factors so we can help you and your organization reduce adverse events and claims. Breakdowns contributed to more than a third of our cases.
Claims involving communication breakdowns are often so complex that they can be similar to a game of Clue®. Was it the nurse discussing the patient's pre-op lab results with the surgeon? Or the medical office tech with an X-ray result that needed to be communicated to the physician? Or the Physician Assistant consulting with the patient, informing them about a needed referral?
In my time as a risk and patient safety professional, I’ve read numerous clinical case summaries and have been shocked by how adverse events unfolded over something as simple as a conversation, not clinical judgment or technical skill concerns.
For example, an elderly woman in a senior living center for rehab died from sepsis due to failure to monitor and appropriately treat her skin pressure injuries. The senior living care team did not communicate about her declining status and did not clarify who among her various clinicians was managing her condition.
In another case, a 16-month delay in diagnosing colon cancer occurred when a physician failed to recognize an abnormal pathology report following a colonoscopy on a woman because the information about the cancerous polyp was buried in the report. The cancer advanced to Stage IV during the delay.
In still another case, a delivering obstetrician failed to mention to the on-call physician that the woman he had just performed a cesarean delivery on had a platelet disorder. The lack of this vital information led to a failure to appreciate hemodynamic changes, causing a surgical delay that contributed to the death of the woman.
These incidents remain with me as a stark reminder of how fragile our system can be and how easily things fall through the cracks when our words fail to find their mark.
Malpractice claims most frequently stem from surgical mistakes or missed diagnoses. However, communication failures consistently rank as one of the top contributing factors. A striking 35% of Curi malpractice cases analyzed involved a communication breakdown.
And when communication fails, the entire system fails—because medicine, at its core, is a team sport. In over half of the claims involving communication breakdowns, it’s usually communication among the team that falls apart, specifically the failure to communicate about the patient's condition.
When something goes wrong—when a patient deteriorates or an abnormal lab result isn't addressed on time—families ask the inevitable question: "Why didn't anyone catch this sooner?" Sometimes, the answer is that someone did, but the concern didn't reach the right ears at the right time.
The fixes aren't easy, but they're vital:
In my experience reviewing malpractice claims, I've seen time and again how communication breakdowns can lead to devastating outcomes—not because of a lack of clinical skill, but because critical information wasn't clearly shared or acted upon. Over a third of recently analyzed Curi claims involved communication failures, and more than half of those happened within the care team itself.
These aren't just unfortunate oversights: They're systemic vulnerabilities. That's why I believe communication must be treated as a core clinical skill. We need to invest in structured tools, team training, and a culture that prioritizes clarity and collaboration. When we hardwire effective communication into our workflows, we don't just reduce risk—we save lives.
Learn more about our Early Intervention program, a better way forward after an unexpected outcome—a way that can preserve relationships, promote communication, and ultimately improve everyone's experience.
Curi clients, sign in to our Risk Solutions Resource Catalog to access our HEAL Early Intervention Toolkit and resources on communication:
If you have questions about this topic, please call 800-328-5532 to speak with one of Curi Advisory's Risk Solutions Consultants.
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