Communication Errors in Health Care: Handoffs, Missed Messages, and Liability
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How “Communication Errors” Can Harm Patients
Health care depends on information reaching the person who must act on it. A message can be missed, delayed, incomplete, misunderstood, routed to the wrong person, or documented without anyone confirming that it was received and addressed. Problems may occur during a shift change, transfer between departments or facilities, consultation, discharge, or follow-up of a test result. Examples include an uncommunicated change in symptoms, an unclear medication or treatment order, a critical imaging or laboratory result that is not escalated, or a pending test that no one tracks after discharge. Patient-safety resources describe handoffs and closed-loop test-result communication as areas where reliable processes matter.
“A Bad Outcome” Does Not Prove Negligent Communication
Communication can break down without causing injury, and patients can be harmed even when the team communicated reasonably. A malpractice claim requires evidence of a duty, a departure from the applicable standard of care, and a causal connection between that departure and the injury. The relevant question is not simply whether a message was imperfect, but whether a reasonably careful professional in that role should have conveyed, received, clarified, escalated, documented, or acted on the information under the circumstances—and whether doing so would probably have changed the outcome.
“Who Had Responsibility” Depends on the Message and Role
Responsibility may involve the person expected to send a result or concern, the clinician assigned to receive or follow it, a consultant asked to provide advice, or a provider responsible for explaining next steps to the patient. Nurses, physicians, trainees, laboratory or imaging personnel, and others can have different duties depending on their roles, the information available, and the facility’s process. A hospital or practice may also be examined for its own systems, staffing, routing, escalation, or follow-up practices, and for vicarious liability where supported by an employment or agency relationship. No one is liable merely because they were somewhere in the chain.
“Evidence” That Can Reconstruct a Communication Failure
The timeline often matters. Relevant evidence can include orders, test-result timestamps, chart notes, handoff or transfer records, secure messages, call and paging logs, electronic health record audit trails, discharge instructions, policies in effect at the time, and testimony about who knew what and when. A note that a message was sent may not alone show who received it or what action followed; the surrounding record and applicable workflow can provide context. Privacy, retention, and access rules may affect what records are available.
“Causation” Requires More Than a Missed Message
To connect a communication lapse to harm, the evidence must support what likely would have happened if the information had been conveyed and acted on in time. That may require expert testimony about the clinical significance of the result or symptom, the response that was indicated, and whether timely action would probably have avoided or reduced the injury. If the patient’s condition would have progressed despite a reasonable response, or the message would not have changed treatment, causation may be disputed. Delayed diagnosis, additional treatment, or a worse prognosis may need separate analysis.
“Maryland Malpractice” and the Claim Process
Maryland health-care malpractice claims generally require proof of the applicable professional standard and a breach that proximately caused compensable injury. Qualified expert testimony is often necessary to explain the duties of the people involved and the medical consequences of the communication failure. Covered claims are subject to the Health Care Alternative Dispute Resolution Office process and statutory expert requirements. Patient-safety recommendations can help explain why a workflow exists, but a guideline or communication breakdown does not by itself decide the legal standard or establish liability.
Related Maryland Cases and Authorities
Patient-safety sources: Agency for Healthcare Research and Quality, “Handoff” and “Communication Between Clinicians”; Md. Code, Cts. & Jud. Proc. §§ 3-2A-04, 3-2A-06B; Md. Rule 5-702; Rochkind v. Stevenson, 471 Md. 1 (2020).