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by Dr Gar LaSalle, MD
Dr LaSalle is Chief Medical Officer, TeamHealth, and Assistant Professor of Emergency Medicine, the University of
Washington, Seattle and Tacoma, and the University of South Florida, Tampa.
The handoff of a patient from an outgoing physician to an incoming physician during a hospital shift change is an activity fraught with the potential for error, as discussed in this issue by Drs Brownstein and Schleyer. The careful transfer of patient information between physicians is central to the continuity of patient care, making the shift change a most crucial time for the patient. Physicians who address the transfer appropriately can directly affect the patient's safety, comfort
level, perceived quality of care, and willingness to openly communicate his or her physical and emotional state.
In addition to an amplified risk for the patient, an improper patient handoff can result in devastating legal consequences if something goes wrong. Malpractice suits that end with a plaintiff's verdict may threaten the livelihood of a physician if he or she is unable to obtain professional liability insurance. Frequently, lawsuits concerning an improper patient handoff involve two or more physicians who, too often, react by pointing fingers at one another. This creates contrasting testimonies, much to the benefit of the plaintiff and the detriment of the physicians.
Since a report by the Institute of Medicine on medical errors was published in 2000,1 much attention has been given to the development and implementation of error-reduction strategies. The industry-wide need to address patient handoffs is evidenced by the 2007 Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations.2 As noted in the November 2006 issue of the Joint Commission Journal on Quality and Patient Safety,3 an unintended consequence of the Accreditation Council for Graduate Medical Education's decision to set limits for resident duty hours in 2003 was that the number of shift changes among interns and residents increased.
The Joint Commission's patient safety goal #2, which addresses the effectiveness of communication among physicians and other caregivers, includes the following clause about patient handoffs: "Implement a standardized approach to ?hand off' communications, including an opportunity to ask and respond to questions."2
Nowhere in patient care is communication more challenging than in the emergency department. Many medical disciplines?each performing separate tasks but working interdependently?are required to communicate in a chaotic, stressful, and rapidly changing environment. This makes all emergency departments especially vulnerable to errors. For this reason, in 2004 TeamHealth, the largest provider of hospital-based clinical outsourcing and administrative services, launched a series of initiatives, including its award-winning "Patient Safety Fables" series of education tools, to facilitate patient handoffs. The series includes short vignettes that are filmed in real emergency departments, using real staff, and feature different physician?patient interaction points. Each vignette lasts less than 3 minutes, illustrating a "bad" and a "good"' way to interact and communicate. The first part of the series is focused on the patient transfer.
The main goals of this initiative were to increase physicians' awareness to the problem of handoffs and to provide enough information to emergency departments to facilitate safe and sound policies and to reduce risk and improve patient safety. The video component of each of the "Patient Safety Fables" is filmed in a first-person perspective through the patient's eyes. One example helps to highlight potential problems in the handoffs.
The patient enters the waiting area, complains of abdominal pain, and after a long wait is escorted to the emergency department examination room. The patient is finally evaluated by a friendly, well-spoken physician. On examination, the physician suspects an inflamed appendix and explains the testing procedure he plans to perform. Waiting for laboratory test results, the patient, still in pain, is comforted once he understands the process of care and what to expect.
After awhile, a different physician appears. He abruptly explains that the scan was negative and that he believes the pain was, "probably a GE or something of that nature." Only after the patient asks does the new physician explain the absence of the first physician and the meaning of "GE." He tells the patient he could go home, and the physician leaves as quickly as he came. The patient is left baffled, confused, and still in pain.
A host of concerns is illuminated in this example of an improper handoff. The second physician enters without introducing himself, uses a medical abbreviation the patient is unlikely to understand, fails to reevaluate the patient, and leaves without offering discharge instructions. However exaggerated this example may be, it is not hard to imagine situations in which these breakdowns do occur.
Patients who arrive at the emergency department are generally in pain, suffering some physical trauma, and anxious. Emergency department physicians are well-trained to address the pain or trauma but are not always attuned to the accompanying anxiety. Ignoring the emotional needs of a patient can result in the inability or unwillingness to accurately report the patient's physical state, thereby hampering the physician's ability to make an accurate diagnosis.
Using tools such as the "Patient Safety Fables" or the mnemonic coined by Drs Brownstein and Schleyer, the physician may have a greater appreciation for the patient concerns inherent in a visit to the emergency department and help reduce the errors in the patient transfer.
Ultimately, the job of the physician is to meet the patient's needs?both clinical and emotional. The transfer of patient care between physicians carries the potential for miscommunication that can result in error, but it is also an opportunity to reassess a patient's physical status and to address the often-overlooked emotional needs of the patient.
The Patient Safety Fables
Since the implementation in 2005 of TeamHealth's patient safety initiative for patient handoffs, hospitals using the "Patient Safety Fables" videos and related toolkits have not had any reported incidents or claims related to handoff failures, suggesting that becoming aware of potential pitfalls and positive interactions can improve patient safety and reduce errors in the handoff of the patient in the emergency department.
TeamHealth is a hospital-based clinical outsourcing company that provides staffing and management services to approximately 600 civilian and military hospitals, with a team of more than 5600 affiliated physicians and other caregivers. For more information, visit
www.teamhealth.com.
References
- Institute of Medicine, Committee on Quality of Health Care in America. Kohn L, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- Joint Commission on Accreditation of Healthcare Organizations. 2007 National Patient Safety Goals. Available at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals.
- Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32:646-655.
