Preventing a Patient Care Fumble: Areas for improvement in patient care hand-offs

Anyone who has been a part of the healthcare system whether as a patient or a healthcare provider has been a part of the patient hand-over system. In fact, it is probably one of the least thought of but high impact processes in the healthcare system. A hand-over is the process by which specific information about a patient is passed from one caregiver to another. There are many scenarios in which such information sharing occurs on a daily basis. Some examples include; one caregiver team to another(patient transferred from emergency room to the unit within the hospital), caregiver to caregiver(nurse to nurse report or physician to physician report), healthcare provider to family caregiver, healthcare provider to patient, and healthcare facility to healthcare facility.

All of the above scenarios occur multiple times on a daily basis. In fact, consider a scenario in which a patient was referred to the emergency room by their primary care provider, then transferred to a hospital unit, be kept in the hospital for three days, sent home and then seen by their primary care provider for follow-up. Under this scenario, patient care hand-overs would have occurred at least fourteen times. During each of those hand-overs, critical information would have been relayed from one caregiver to another. Information such as medical history, current health status, current medications, any allergies to medications, doctors orders, discharge orders and patient follow-ups.

The breakdowns that occur during these handovers were the leading root causes of sentinel events according to Joint Commission from 1995-2006. Some malpractice insurance companies cited such breakdowns as being one of their top reasons for payouts. Some of the breakdowns that were noted to occur were missing critical pieces of patient history(for example, not communicating that a heart patient is also diabetic), not communicating medication allergies, not communicating physician orders correctly, lack of discharge teaching to the patient or their family, not communicating safety precautions regarding a patient(need for fall precautions for a patient).

There are several organizations that are looking at the solutions to this problem. Some of the proposed solutions are:

• Streamlining and standardizing change of care reports
• Requiring healthcare practitioners to read-back the information they have recorded during report to ensure that information has been transferred as intended
• Electronic patient sign-outs for formal documentation that healthcare providers shared appropriate information
• Multidisciplinary rounds so that all members of healthcare team understand same information about a patient

For more information on this topic or if you have questions about a medical record that may have been effected by an ineffective patient hand-over, please contact our office.

Reference:

World Health Organization. (May 2007) Patient Safety Solutions: Communication During Patient Hand-Overs. Retrieved August 2007 from www.jcaho.org

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