Reducing Errors During Patient-Care Handoffs

Providing medical care to patients in the hospital setting has become increasingly complicated. Large amounts of clinical data need to be processed, and new rules governing resident and fellow hours have resulted in fragmented care. There have been many initiatives to improve hospital care, and it is a process that needs continuous reevaluation and updating.

Communication between physicians has been identified as an area in which many mistakes happen. These can lead to potentially negative outcomes for our patients, such as prolonged hospital stay or death.¹ In 2003, the Accreditation Council for Graduate Medical Education instituted limits on the number of hours that residents can work in the hospital per 24-hour period. Although the goal was to improve patient safety by decreasing fatigue among residents, it had unintended consequences. The rules led to the increased need for multiple handoffs of patient care among residents, fellows, and attending physicians in the inpatient setting. Unfortunately, these communications are often not standardized and may lead to disastrous results.

Change-of-Care Perils

The change of physician on duty can be a perilous time for the patients, because the majority of medical errors resulting in liability have been traced to miscommunications.^2,3 The errors resulting from poor handoffs can include incomplete or incorrect lists of medications, incorrect code statuses, and inaccurate laboratory results. But the most serious mistakes are errors of omission, when the events of the last 12 to 24 hours are not relayed and the new physician does not have an accurate picture of the patient’s health.

In the studies that examined liability claims, 26% to 31% of events were due to errors in communication.^2,3 There are not many data that directly evaluate physician-to-physician communication at the time of patient-care handoff. Specifically, there is a lack of data about teams caring for patients on internal medicine hospital services, although a few studies report an alarmingly high rate of errors and omissions during change-of-care times.⁴

Over the past 5 years, the Joint Commission has made standardized communications a priority among physicians performing patient- care handoffs. However, there is no concerted effort to evaluate and recommend the most efficient and reliable methods. Individual institutions have designed their own solutions, although there are no high-quality data on which approaches lead to better outcomes in patient care and safety. Most institutions now use some form of electronic board that can be updated by various members of the team.⁵

Unfortunately, there is great variation among different institutions and their approach to patient-care handoffs.⁶ Some of the differences stem from the fact that there are many solutions to the resident-hour rules, ranging from the night-float system to residents staying overnight in the hospital and leaving early in the morning. It is disturbing to learn that the process was not standardized across institutions nor within specific programs.⁶ These observations call attention to the lack of high-quality data needed to help institutions implement solutions that would assure patient safety, and to the lack of education for physicians and residents on how to efficiently and thoroughly communicate patient information to other physicians.

The uniform standardization of patient handoffs across all institutions might not be possible or even desirable due to the differences between academic institutions and private institutions. Also, hospital services caring for certain patient populations have their own requirements and points of emphasis specific to their specialties. Internal medicine services and especially hematology and oncology inpatient services have increasingly complex patients with multiple medical problems. It is imperative that physicians caring for these patients have up-to-date and accurate information.

Several existing studies offer recommendations to make the process safer. Face-to-face interactions between the 2 parties is essential in limiting errors.⁷ This allows the physicians to ask questions and clarify information, resulting in more accurate patient data being transferred. Interruption- free time was also important in ensuring an error-free transfer of care. Computerized systems that automatically pull information from patients’ charts help to reduce errors and make the process more efficient.⁸

Consistency in Communication

It is clear that the process of patient-care handoffs must be made safer and more efficient. The increasing implementation of sophisticated software programs will most likely improve the accuracy of the information as well as the efficiency of the process. Unfortunately, these ancillary products will not be able to replace a physician’s necessary clinical acumen. One of the most important parts of the change of care is anticipation of potential problems and designing appropriate responses. All doctors do this to some degree while caring for their patients—often subconsciously. The challenge lies in communicating this information to others. No software program will be able to replace this interaction. Medical schools and residency programs will need to introduce or expand existing programs in teaching physicians the necessary methods to effectively and concisely hand off the care of their patients to new care teams. Likewise, institutions must continually reevaluate the process to decrease the number of poor patient-care handoffs, leading directly to improved patient safety.

REFERENCES

1. Pham JG, Aswani MS, Rosen M, et al. Reducing medical errors and adverse events [published online ahead of print January 26, 2011]. Annu Rev Med.

2. White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5, pt 1):1031-1038.

3. White AA, Wright SW, Blanco R, et al. Cause-and-effect analysis of risk management files to assess patient care in the emergency department. Acad Emerg Med. 2004;11(10):1035-1041.

4. Sehgal NL, Auerbach AA. Communication failures and a call for new systems to promote patient safety: comment on “structured interdisciplinary rounds in a medical teaching unit.” Arch Intern Med. 2011;171(7):684-685.

5. Kannry J, Moore C. MediSign: using a Web-based signout system to improve provider identification. Proc AMIA Symp. 1999;550-554.

6. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-1177.

7. Alvarado K, Lee R, Christoffersen E, et al. Transfer of accountability: transforming shift handover to enhance patient safety. Healthcare Q. 2006;9 spec no:75-79.

8. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24(2):77-87.