Care Transitions Risky for Patients

A Chicago team surveyed medical residents and found harrowing tales of mishaps and near-misses due to botched handoffs when patients are stepped down from ICU care.

When patients transfer from the intensive care unit to the wards, mishaps related to communication lapses often happen.

Reporting at the American Thoracic Society meeting in Denver, CO, Jeanne Farnan, MD, MHPE of the University of Chicago Medicine, Chicago, IL and colleagues presented results of a survey of medical residents. The team interviewed residents in inpatient general medicine, oncology, and cardiology rotations from Oct. 2013 and January 2014, asking them about near-miss and adverse events due to ineffective handoffs of such patients.

Of 29 residents interviewed, 19 (66%) reported 27 adverse events or near misses experienced by patients due to communication failures.

The 3 major categories of these glitches were missing information, incorrect information, and lack of clarity on who was responsible for a patient during the handoff process.

Four incidents were linked to patient deaths and 6 were near-misses that could have been fatal.

Their report, due to be presented in a poster session at the meeting, lists harrowing examples.

One death was traced to incorrect information that a patient did not need anticoagulation therapy. “She ended up developing pulmonary embolisms and died,” the resident said in the survey.

In another, a patient and family were listed as having agreed to hospice care when they did not and “in fact, adamantly refused.”

In a third case, the patient’s records did not include a crucial chest radiograph that would have a direct impact on care.

The authors also found that residents felt they spend far too little time on these handoffs.

“Our results highlight the ubiquity of miscommunication and the risk of medical error when patients transfer from the ICU to the wards,” they concluded, and a need for interventions to change this common situation.