Communication breakdowns are part of life.

Very regularly, well-intentioned people are unclear, misunderstand, or fail to act. Still, communication breakdowns in the reporting of critical medical test results can be catastrophic, so health professionals must continually work to close the loop on systemic issues involving communication, including the timely relaying of critical values, patient handoff from one provider to the next, and follow-through procedures.

In the 35 years since the Medical Professional Liability Association has been compiling information from insurers, diagnostic error has consistently been one of the top reasons doctors are sued.

You could do everything right. You could make a judgment that isn't questioned by your peers. You could meet the standard of care. But the patient could still be harmed--and then you could be sued.

That’s what happened to Dr. Dalvi, a Seattle radiologist. And what happened to his patient, Allison Carter, baffled the many medical providers she encountered in October 2014.

In the following case, the names of people and facilities have been modified for privacy protection. Consider how each component affected the diagnostic process and the eventual outcome.

Medical Errors are a leading cause of death in the United States, causing preventable harm to around 400,000 Americans annually, at a cost of approximately $20 billion per year.

In "Preventing Medical Injury," published in the Quality Review Bulletin, researchers define four types of medical errors: diagnostic errors, including missed or delayed diagnosis; treatment errors, which include medication mistakes; preventative errors, or the failure to provide protective monitoring or care; and other errors, which include communication failures.

In 2015, Improving Diagnosis in Health noted 5% of U.S. adults seeking outpatient care experienced diagnostic error.

A review of inpatient event reports indicates that diagnostic errors account for 6–17% of reported adverse events,1 and failure to respond to new, actionable information is a frequent cause of diagnostic error in both the outpatient and inpatient settings.

Diagnostic errors are the most common, most catastrophic, and most costly of all medical errors. Every year in the United
States, 12 million adults are impacted in outpatient settings alone by delayed or inaccurate diagnoses. Approximately

How EvergreenHealth managed the first known coronavirus outbreak in the U.S.—and what they’re doing now.

EvergreenHealth in Kirkland, Washington, found itself under the global spotlight this past February as they reported the first death from COVID-19 in the United States. Located near the Life Care Center of Kirkland long-term-care facility, EvergreenHealth treated dozens of Life Care patients in the first major coronavirus outbreak before the disease rippled across America and the globe.

While in rural Oregon during his residency in 2014, Dr. Anthony Cheng never guessed that he’d glimpse the future of how medicine would be delivered during a pandemic. But what he experienced during that formative time in his career intrigued him about the possibilities of telehealth.

Allegro Pediatrics—Brett Vandenberg, CMPE Chief Executive Officer

OF ALL THE SURPRISES THAT CAME ALONG WITH COVID-19, WAS THERE ANYTHING THAT STOOD OUT?

Before the novel coronavirus (COVID-19), telehealth adoption in ambulatory care was inconsistent.¹ Now, many clinicians have been dumped in at the telehealth deep end—and it’s sink or swim.^2,3 Without the ability to provide healthcare for payment, primary-care clinicians unable to offer video visits are vulnerable to financial collapse.^4–7 And in the post-pandemic future, those without video visits will likely remain vulnerable, as telehealth has become an essential modality of care.