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The Handoff: A Critical Point of Vulnerability

by Christopher P. Landrigan, MD, MPH
Reprinted with permission by CRICO/Risk Management Foundation of the Harvard Medical Institutions.
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Dr Landrigan is Director of the Sleep and Patient Safety Program, Division of Sleep Medicine and Brigham and Women’s Hospital (Boston); Research and Fellowship Director, Inpatient Pediatrics Service at Children’s Hospital Boston; and an Assistant Professor of Pediatrics and Medicine at Harvard Medical School

Over the past decade, communication failures have become widely recognized as a leading safety hazard in health care. In root cause analyses, nearly 80 percent of serious medical errors involve miscommunications.1 The Joint Commission, the National Quality Foundation, and the Department of Defense Patient Safety Center have each called for the development of high-quality communication tools and processes with a goal toward ensuring the critical patient information gets appropriately transmitted and received.2-4

The “handoff,” i.e., the transfer of patient information and responsibility between health care providers, is an especially critical point of vulnerability to communication error. 5-7 Handsoffs occur at every hospital shift change, and whenever patient changes locations. Omissions of critical information— as well as provision of outdated or frankly erroneous information—occur frequently.8 Exacerbating this problem are: 1) the rising acuity of hospitalized patients; 2) the need for complex teams of primary providers and sub-specialists to care for sicker patients; and 3) resident- physician work hour reductions.9-12

Discontinuities in care pose a risk to safety, but only a few studies have qualified those risks, and even fewer have evaluated the use of communication technologies to improve the handoff process (and , thus, patient safety). Some examples:

Researchers investigating resident work hour reduction in New York State found that the presumed increase in discontinuity caused by the institution of night-float systems resulted in delayed test ordering and an increase in hospital complications.13

Petersen at al evaluated potentially preventable adverse events were much more likely to occur if the patient was under the care of a physical from a “non-primary” team (e.g., the cross-covering or night-float intern).14

Similarly, in a military setting (specifically, a university-affiliated Veterans Administration Hospital) Patients admitted by resident night-floats had longer lengths of stay and increased laboratory testing.15

Investigators affiliated with Harvard Medical School have been involved in a number of studies that have shed further light on this issue. The first was a randomized trial of a scheduling intervention that eliminated 24-hour shifts and reduced office hours while at the same time introducing an additional handoff in care (due to reduced work hours).16 The intervention did result in a significant overall reduction in serious diagnostic errors—however, avoidable miscommunications were still reported. That study has led to a strong interest in developing communication tools to assist with scheduling interventions.

In a recent study of handoffs from the operating room to the ICU, communication errors occurred in 100 precent of sign-outs; most contained multiple errors.17 Many of those errors could have been prevented with the use of a simple, computerized sign-out tool.

In a focus group study of residents from Boston’s Brigham and Women’s Hospital (BWH) and two other academic centers, it was found that a wide variation occurred both in the process and content of of sign-out.18 At BWH in particular only 52 precent of residents provided written and oral sign-out on every patient, and only 86 precent updated the written sign-out on a daily basis. Only 55 precent of night-float residents repotted that the relevant information was available in the sign-out at night when needed.19

To date, the adoption of computerized sign-out tools has been slow, in part due to a limited availability of high quality commercial or widely disseminated products, An enhanced, structured computer sign-out has been found, in one study, to reduce the risk of adverse events associated with cross-coverage of patients by house staff less familiar with them.20

As noted, some preliminary studies indicate that improved sign-out processes and tools hold promise of further improving care. But, before wide spread implementation can occur, further evidence of their effectiveness is needed, as is refinement for use in diverse environments.

1 Summary, April 2006. http://www.va.gov/ncps/mtt/ExecSummary.pdf

2 US Department of Defense Patient Safety Program. Welcome to TeamSTEPPS: Team Strategies and Tools to Enhance Performance & Patient Safety. 2006.

3 National Quality Forum, Agency for Healthcare Research and Quality. Safe Practices for Better Healthcare: A Consensus Report. 2003.

4 Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals for 2006.

5 Cooper JB, Long CD, Newbower RS, Phillip JH. Critical incidents associated with intraoperative exchanges of Anesthesia personnel. Anesthesiology. 1982; 56(6): 456-61

6 Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Qual Saf Health Care. 2002; 11(3):277—82.

7 McCarthy Jl. Narrowing the Focus for Patient Safety 2006 February 2006: 1—3. CRICO/RMF Forum 2006; February:1—3

8 Mistry KP, Landrigan CP, Goldmann DA, Bates DW. Communication during post-operative patient hand off in the pediatric intensive care unit. Crit Care Med. 2005; 33:A12.

9 Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004; 351(18):1829-37.

10 Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351(18):1838-48.

11 Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005; 352(2):125—34.

12 Ayas NT, Barger LK, Cade BE, et al. Extended word duration and the risk of self-reported percutaneous injuries in interns. LAMA. 2006; 296(9):1055-62.

13 Laine C, GoldmanL, Soukup JR, Hayes JG, The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 1993;269:374-8.

14 Petersen LA, Brennan TA, O’Neil AC, et al, Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Int Med. 1994;121 :866—72

15 Lofgren RP, Gottlieb D, Williams Ra, et al. Post-call transfer of resident responsibility: its effect on patient care. JGIM. 1990;5:501—5

16 Landrigan et al, 2004

17 Mistry et al., 2005

18 Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006; 1 : 257-66.

19 Carty M, Smith CC Schnipper JL. Intern curriculum: the impact of a focused training program on the process and content of signing out patients. Society of General internal Medicine Annual Meeting, New Orleans, LA 2005.

20 Petersen LA, Orav EJ, Teich JM, et al. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. J Comm Journal QI.  1998;24:77—87.