HANDOFF FROM THE PATIENT/FAMILY PERSPECTIVE
Ms. Clark’s father had a coronary bypass at age 72. She anticipated trouble because of his alcoholism. She left messages for the surgeon about it, but she never had the chance to speak with him.
Upon being extubated after surgery, her father became very disoriented and combative, insisting he had to leave. The nurse came out to the waiting room to ask her, “Could your father possibly be an alcoholic?” She said yes, definitely, he drinks a lot every day, right up to the night before surgery. The nurse got an order for Librium and gave him a single dose. He calmed down and was transferred to another unit.
That evening he again became confused and combative. Ms. Clark asked the nurse to give him Librium on a round-the-clock basis rather than waiting for him to have full-blown withdrawal symptoms again. Each day, he was transferred to another unit, ICU to stepdown, stepdown to something else, then to a general floor. And every day, she asked the assigned nurse to please dose him round-the-clock.
Each day, her father became wildly combative and disoriented again—and every time it came as a surprise to the staff. He received “as needed” Librium dosing, but only after he went wild. He had drenching night sweats, pulled out his Foley and IV, and tried to take on the Physical Therapy team in hand-to-hand combat.
On the fourth day he asked for his clothes and shoes. Ms. Clark alerted the nurse that he seemed to be planning an escape and again requested round-the-clock Librium dosing. The next day she drove to the hospital to pick him up for discharge. She arrived to find he had already escaped. He hitchhiked home 35 miles in a hospital gown, pants and street shoes.
It was clear to her that between physician and nurse, between one unit and another, between one shift and another, there had been no communication among the staff about the patient’s important medical problem: alcohol withdrawal.
Ms. Clark stated, “You would think it would make the staff’s lives easier to anticipate the withdrawal and medicate him for it. But there seemed to be zero appreciation that alcohol withdrawal is a dangerous medical condition. It was as if it wasn’t cardiac so it didn’t exist, it wasn’t worthy of mention to the next shift.”
The handoff in medicine has been defined as a process “in which patient care and accountability is transferred from one clinician (or team of clinicians) to another.”1 By its nature, inpatient care is complex, requiring multiple transitions in care. There is ample data in many settings to support that the patient handoff can be highly error-prone and associated with patient harm and medical malpractice claims.2-4 Numerous authoritative sources cite communication failures and especially omissions in handoffs as a prominent source of medical error and patient harm. The Joint Commission found that 79% of all sentinel events* result from failures in communication.
*What’s a sentinel event? The Joint Commission definition of a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.”5
Source: The Joint Commission Sentinel Events. 2015 6
Patient harm is a downstream consequence of inadequate transfer of information in the handoff.1 This inadequate information transfer is associated with unstructured, on-the-fly reporting7 especially when all the key parties are not present. While the handoff is a point where an error may be introduced, it is also a point where an error may be caught and corrected by the introduction of a standardized reporting format. Standardized formats customized to the patient setting have been implemented and studied with good result: fewer omissions in information transfer. The presence of key staff at the handoff has also been associated with better information transfer and higher ratings of professionalism and teamwork.1
To reduce the risk at handoff, Medical Interactive, LAMMICO’s subsidiary risk management education company, created a section on Communications available free to LAMMICO insured physicians, nurses and institutions. This section includes several setting-specific activities with guidance on how to improve handoffs:
Handoffs from OR to ICU
Anesthesia Handoff Communications
Hospitalist Handoff Communications
Emergency Department (ED) Handoff Communications
Nursing Handoff Communications
Log in as a Member at lammico.com/login to access these activities.