Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Critical aspects of emergency department documentation and communication

This article focuses on the unique environment of the emergency department (ED) and the issues that place the provider at increased risk of liability actions. Patient care, quality, and safety should always be the primary focus of ED providers. However, the ED chart is the only lasting record of an ED visit, and attention must be paid to proper and accurate documentation. This article introduces the important aspects of ED documentation and communication, with specific focus on key areas of medico-legal risk, the advantages and disadvantages of the available types of ED medical records, the critical transition points of patient handoffs and changes of shift, and the ideal manner to craft effective discharge and follow-up instructions.

Communication failure in the intensive care unit--learning from a near miss

A 51-year-old female patient with Guillain-Barré syndrome was given three times the intended dose of intravenous human immunoglobulin while admitted to a tertiary intensive care unit. The error went unnoticed for seven hours and appears to have been the result of several successive breakdowns in communication between key staff The patient, fortunately, made a full recovery. This report analyses the communication failure and explores possible ways of avoiding similar occurrences in the future.

Discuss now, document later: CIS/CPOE perceived to be a 'shift behind' in the ICU

Effective communication is essential to safe and efficient patient care. We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. Clinicians used a CIS/CPOE system and paper artifacts for documentation; yet, preferred verbal communication as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the CIS/CPOE is a "shift behind" may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication.

The Development of a Web-based Resident Sign-out Training Program

Patient sign-out is a mechanism for transferring information, responsibility, and/or authority from one set of caregivers to another. Little research has addressed what information should be communicated during sign-out and how sign-out should be conducted and evaluated. As hospital residents conduct many sign-outs and have limited time in general, targeted web-based training and evaluation have the potential to enhance Graduate Medical Education. However there are no web-based training systems for this very important skill. This paper presents the operational concept and system requirements for a web-based sign-out training system. It discusses an initial functional prototype. Results of a heuristic evaluation and an assessment of areas for improvement are presented.

Canadian Association of University Surgeons annual symposium: Continuity of care: Toronto, Ontario, Sep. 6, 2007

This 2007 symposium of the Canadian Association of University Surgeons brought together surgeons from a number of jurisdictions to discuss the challenges and opportunities that reduced physician work hours will bring to the care of the surgical patient. Dr. Brian Taylor, president of the association, underscored the need to find a balance between the benefits of diminished workloads/work hours and the loss of continuity of care. He opined that Canada needs to learn from our European colleagues' experience. Dr. Per-Olof Nyström, professor of surgery, presented the modern Swedish model of surgical care, which had to be developed as a consequence of the European Union's legal restrictions on the amount of time an individual surgeon may work. Sweden employs a team-based shared-care model driven by the individual surgeon's expertise rather than the "village factory" model of the multiskilled, multitasking approach of surgical care more prevalent in Canada. Dr. Chris de Gara, secretary treasurer of the association, presented the evidence base for (and against) work-hour restrictions and how well-designed systems can ensure effective continuity of care. Dr. Stewart Hamilton illustrated how one such system for the delivery of the emergency general surgical services has evolved at the University of Alberta Hospital, which demonstrated its effectiveness in providing quality surgical continuity of care. Dr. Debrah Wirtzfeld underscored the importance of trainee lifestyle and how modern Web-based technologies can ensure reduced errors with the implementation of a "sign-out" system.

Residents' and attending physicians' handoffs: a systematic review of the literature

PURPOSE

Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective.

METHOD

The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors.

RESULTS

Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness.

CONCLUSIONS

Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment

STUDY OBJECTIVE

We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.

METHODS

This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.

RESULTS

The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.

CONCLUSION

We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician-to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover

OBJECTIVE

To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety.

DESIGN

Handover assessment instrument development study divided into two phases by the introduction of a handover intervention.

SETTING

Closed, 17-bed, university-affiliated mixed surgical/medical intensive care unit.

SUBJECTS

Senior and junior medical members of the intensive care unit team.

INTERVENTIONS

Electronic handover page.

MEASUREMENTS AND MAIN RESULTS

Study subjects were asked to recall clinical information commonly discussed at handover on individual patients. The handover score measured the percentage of information correctly retained for each individual doctor-patient interaction. The clinical intention score, a subjective measure of medical judgment, was graded (1-5) by three blinded intensive care unit experts. A total of 137 interactions were scored. Median (interquartile range) handover scores for phases 1 and 2 were 79.07% (67.44-84.50) and 83.72% (76.16-88.37), respectively. Score variance was reduced by the handover intervention (p < .05). Increasing median handover scores, 68.60 to 83.72, were associated with increases in clinical intention scores from 1 to 5 (chi-square = 23.59, df = 4, p < .0001).

CONCLUSIONS

When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.

Understanding communication during hospitalist service changes: a mixed methods study

BACKGROUND

Little data exist to inform hospitalist communication during service changes.

OBJECTIVE

To characterize hospitalist handoffs during service changes.

DESIGN

Serial survey study.

SETTING

Single academic medical center.

MEASUREMENTS

From May to December 2007, 60 service changes among 17 hospitalists on a nonteaching service were targeted for evaluation using an anonymous 18-item survey that was completed by hospitalists within 48 hours of assuming care for patients. Survey items assessed completeness of handoff communication, certainty of patient care plans, missed information, time spent recovering information, and near misses/adverse events due to incomplete handoffs. The association between completeness of communication and handoff outcomes was examined. Narrative comments were analyzed qualitatively.

RESULTS

Ninety-three percent (56/60) of surveys were returned. All 17 hospitalists participated. Thirteen percent of respondents reported incomplete handoffs and 18% were uncertain of care plan on transition day. At least 1 near miss, attributable to incomplete communication was reported by 16%. Hospitalists who reported incomplete handoffs were more likely to report uncertainty about patient care plans on the transition day (71% incomplete vs. 10% complete, P < 0.01), discovery of missing information (71% incomplete vs. 24% complete, P = 0.01), near misses/adverse events (57% incomplete vs. 10% complete, P < 0.01), and more time resolving issues arising from missed information (71% incomplete vs. 22% complete, P < 0.01). Qualitative comments suggest the need for a more systematic, focused, team-based, and patient-centered handoff model.

CONCLUSIONS

Incomplete handoffs during service changes are associated with uncertainty and potential patient harm. Suggestions to improve the completeness of hospitalist service change communications are offered.

Improving handoffs in the emergency department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND

Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem.

METHODS

We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up.

RESULTS

Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment.

CONCLUSIONS

Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions

STUDY OBJECTIVE

Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out.

METHODS

A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques.

RESULTS

During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval -0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval -27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67).

CONCLUSION

Voicemail sign-out for ED-internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.

Assessing patient safety culture of internal medicine house staff in an academic teaching hospital

PURPOSE

Patient safety culture (PSC) examines how individuals perceive an organization's commitment and proficiency in health and safety management. The primary objective of this study was to assess hospital PSC from the perspective of internal medicine house staff, and to compare the results by postgraduate year (PGY) of training and to national hospital benchmark data.

METHODS

The authors modified and used a version of the Hospital Survey on Patient Safety Culture (HSOPSC), which has 12 PSC dimensions. Each dimension uses a 5-level Likert scale of agreement ("Strongly disagree" to "Strongly agree") or frequency ("Never" to "Always"). The survey was distributed to 68 PGY-2 and PGY-3 internal medicine house staff at an academic medical center between December 2006 and February 2007. Composite scores were created for each respondent by calculating the proportion of positive responses for each domain. Domain score means were compared between PGYs and to survey data from hospitals that administered the HSOPSC (ie, benchmark data).

RESULTS

The overall response rate was 85.3% (58/68). House staff scored lower on 6 and 4 of the 12 PSC dimensions, when compared with the overall national hospital and medicine unit benchmarks, respectively (P < .05). PGY-3 staff scored lower than PGY-2 staff in 2 dimensions (P < .05).

CONCLUSIONS

PGY-2 and PGY-3 internal medicine house staff at our institution were in agreement on most of the PSC dimensions. Overall, house staff PSC was significantly lower than national hospital benchmark data for half of the dimensions. The results of this study will be used to establish internal PSC benchmarks and to identify targets for interventions to further improve PSC.

Hospitalist handoffs: a systematic review and task force recommendations

BACKGROUND

Handoffs are ubiquitous to Hospital Medicine and are considered a vulnerable time for patient safety.

PURPOSE

To develop recommendations for hospitalist handoffs during shift change and service change.

DATA SOURCES

PubMed (through January 2007), Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, white papers, and hand search of article bibliographies.

STUDY SELECTION

Controlled studies evaluating interventions to improve in-hospital handoffs (n = 10).

DATA EXTRACTION

Studies were abstracted for design, setting, target, outcomes (including patient-level, staff-level, or system-level outcomes), and relevance to hospitalists.

DATA SYNTHESIS

Although there were no studies of hospitalist handoffs, the existing literature from related disciplines and expert opinion support the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. Technology solutions were associated with a reduction in preventable adverse events, improved satisfaction with handoff quality, and improved provider identification. Nursing studies demonstrate that supplementing verbal exchange with a written medium leads to improved retention of information. White papers characterized effective verbal exchange, as focusing on ill patients and actions required, with time for questions and minimal interruptions. In addition, content should be updated daily to ensure communication of the latest clinical information. Using this literature, recommendations for hospitalist handoffs are presented with corresponding levels of evidence. Recommendations were reviewed by hospitalists at the Society of Hospital Medicine (SHM) Annual Meeting and by an interdisciplinary team of expert consultants and were endorsed by the SHM governing board.

CONCLUSIONS

The systematic review and resulting recommendations provide hospitalists a starting point from which to improve in-hospital handoffs.

What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff

OBJECTIVES

To characterise and assess sign-out practices among internal medicine house staff, and to identify contributing factors to sign-out quality.

DESIGN

Prospective audiotape study.

SETTING

Medical wards of an acute teaching hospital.

PARTICIPANTS

Eight internal medicine house staff teams.

MEASUREMENTS

Quantitative and qualitative assessments of sign-out content, clarity of language, environment, and factors affecting quality and comprehensiveness of oral sign-out.

RESULTS

Sign-out sessions (n = 88) contained 503 patient sign-outs. Complete written sign-outs accompanying 50/88 sign-out sessions (57%) were collected. The median duration of sign-out was 35 s (IQR 19-62) per patient. The combined oral and written sign-outs described clinical condition, hospital course and whether or not there was a task to be completed for 184/298 (62%) of patients. The least commonly conveyed was the patient's current clinical condition, described in 249/503 (50%) of oral sign-outs and 117/306 (38%) of written sign-outs. Most patient sign-outs (298/503, 59%) included no questions from the sign-out recipient (median 0, IQR 0-1). Five factors were associated with a higher rate of oral content inclusion: familiarity with the patient, sense of responsibility for the patient, only one sign-out per day, presence of a senior resident and a comprehensive written sign-out. Omissions and mischaracterisations of data were present in 22% of sign-outs repeated in a single day.

CONCLUSIONS

Sign-outs are not uniformly comprehensive and include few questions. The findings suggest that several changes may be required to improve sign-out quality, including standardising key content, minimising sign-outs that do not involve the primary team, templating written sign-outs, emphasising the role of sign-out in maintaining patient safety and fostering a sense of direct responsibility for patients among covering staff.

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire

BACKGROUND

Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable.

METHODS

All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable.

RESULTS

Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns.

CONCLUSION

RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.

Communication channels in general internal medicine: a description of baseline patterns for improved interprofessional collaboration

General internal medicine (GIM) is a communicatively complex specialty because of its diverse patient population and the number and diversity of health care providers working on a medicine ward. Effective interprofessional communication in such information-intensive environments is critical to achieving optimal patient care. Few empirical studies have explored the ways in which health professionals exchange patient information and the implications of their chosen communication forms. In this article, we report on an ethnographic study of health professionals' communication in two GIM wards through the lens of communication genre theory. We categorize and explore communication in GIM into two genre sets-synchronous and asynchronous-and analyze the relationship between them. Our findings reveal an essential relationship between synchronous and asynchronous modes of communication that has implications for the effectiveness of interprofessional collaboration in this and similar health care settings, and is intended to inform efforts to overcome existing interprofessional communication barriers.

Evaluation of a physician informatics tool to improve patient handoffs

OBJECTIVE To facilitate patient handoffs between physicians, the computerized patient handoff tool (PHT) extracts information from the electronic health record to populate a form that is printed and given to the cross-cover physician. OBJECTIVES were to: (1) evaluate the rate at which data elements of interest were extracted from the electronic health record into the PHT, (2) assess the frequency for needing information beyond that contained in the PHT and where obtained, (3) assess physician's perceptions of the PHT, (4) identify opportunities for improvement. DESIGN Observational study. MEASUREMENTS This multi-method study included content coding of PHT forms, end of shift surveys of cross-cover resident physicians, and semi-structured interviews to identify opportunities for improvement. Thirty-five of 42 internal medicine resident physicians participated. Measures included: 1264 PHT forms coded for type of information, 63 end-of-shift surveys of cross-cover residents (residents could participate 2 times), and 18 semi-structured interviews. RESULTS For objective 1, patient identifiers and medications were reliably extracted (>98%). Other types of information-allergies and code status-were more variable (<50%). For objective 2, nearly a quarter of respondents required information from physician notes not available in the PHT. For objective 3, respondents found that the PHT supported handoffs but indicated that it often excluded the assessment and plan. For objective 4, residents suggested including treatment plans. CONCLUSIONS The PHT reliably extracts information from the electronic health record. Respondents found the PHT to be suitable, although opportunities for improvement were identified.

Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward

BACKGROUND

Prior research on reducing variation in housestaff handoff procedures have depended on proprietary checkout software. Use of low-technology standardization techniques has not been widely studied.

PURPOSE

We wished to determine if standardizing the process of intern sign-out using low-technology sign-out tools could reduce perception of errors and missing handoff data.

METHODS

We conducted a pre-post prospective study of a cohort of 34 interns on a general internal medicine ward. Night interns coming off duty and day interns reassuming care were surveyed on their perception of erroneous sign-out data, mistakes made by the night intern overnight, and occurrences unanticipated by sign-out. Trainee satisfaction with the sign-out process was assessed with a 5-point Likert survey.

RESULTS

There were 399 intern surveys performed 8 weeks before and 6 weeks after the introduction of a standardized sign-out form. The response rate was 95% for the night interns and 70% for the interns reassuming care in the morning. After the standardized form was introduced, night interns were significantly (p < .003) less likely to detect missing sign-out data including missing important diseases, contingency plans, or medications. Standardized sign-out did not significantly alter the frequency of dropped tasks or missed lab and X-ray data as perceived by the night intern. However, the day teams thought there were significantly less perceived errors on the part of the night intern (p = .001) after introduction of the standardized sign-out sheet. There was no difference in mean Likert scores of resident satisfaction with sign-out before and after the intervention.

CONCLUSION

Standardized written sign-out sheets significantly improve the completeness and effectiveness of handoffs between night and day interns. Further research is needed to determine if these process improvements are related to better patient outcomes.

Critical care physician cognitive task analysis: an exploratory study

Introduction

For better or worse, the imposition of work-hour limitations on house-staff has imperiled continuity and/or improved decision-making. Regardless, the workflow of every physician team in every academic medical centre has been irrevocably altered. We explored the use of cognitive task analysis (CTA) techniques, most commonly used in other high-stress and time-sensitive environments, to analyse key cognitive activities in critical care medicine. The study objective was to assess the usefulness of CTA as an analytical tool in order that physician cognitive tasks may be understood and redistributed within the work-hour limited medical decision-making teams.

Methods

After approval from each Institutional Review Board, two intensive care units (ICUs) within major university teaching hospitals served as data collection sites for CTA observations and interviews of critical care providers.

Results

Five broad categories of cognitive activities were identified: pattern recognition; uncertainty management; strategic vs. tactical thinking; team coordination and maintenance of common ground; and creation and transfer of meaning through stories.

Conclusions

CTA within the framework of Naturalistic Decision Making is a useful tool to understand the critical care process of decision-making and communication. The separation of strategic and tactical thinking has implications for workflow redesign. Given the global push for work-hour limitations, such workflow redesign is occurring. Further work with CTA techniques will provide important insights toward rational, rather than random, workflow changes.

The science and economics of improving clinical communication

This article presents a complex clinical scenario based on actual communication breakdowns that led to a sentinel event. Basic communication theory that underlies clinical interactions and the tenets of health care economic evaluation are reviewed. The process of the handoff as it relates to clinical interactions is discussed and the weaknesses in communication arising from handoff failures in the operative and critical care environments are examined. The discussion follows by looking at the influences of current medical culture, emerging technology, and changing care environments and their impact on communication behaviors and resultant effect on patient outcomes. A detailed cost analysis of the charges incurred for both standard and escalated care required for the case is followed by a discussion of the economic basis for improving clinical communication and patient safety using the SBAR tool.

Poets, doctors, and the rhetoric of money

OBJECTIVE

Greek poets from the archaic and early classical periods frequently depicted doctors alongside political and military leaders and victorious sportsmen. The mythology of ancient physicians found in such sources may give us clues as to how doctors could be viewed and represented by other segments of society, then and now.

METHODS

Pindar's Third Pythian Ode from the first quarter of the 5th century BCE was investigated with reference to other classical sources to understand the contemporary portrayal of ancient physicians.

RESULTS

The Greek hero Asclepius is often recognized as the mythical father of surgery. Pindar's portrayal of Asclepius as a heroic but morally flawed physician and surgeon provides clues to the ambivalent role and identity of physicians in the late archaic period. In particular, the primacy of the moral framework surrounding different types of exchange in late archaic society is identified as a key factor influencing the perception of physicians, poets, and other professionals.

CONCLUSION

The portrayal of physicians in ancient poetry and sculpture may inform modern neurosurgery and organized medicine about strategies by which we may best serve our patients and elevate our profession.

Handoffs causing patient harm: a survey of medical and surgical house staff

BACKGROUND

Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their handoffpractices and the frequency with which they perceive problems with handoffs lead to patient harm.

METHODS

A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%).

RESULTS

Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always.

DISCUSSION

Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.

Conceptualizing handover strategies at change of shift in the emergency department: a grounded theory study

Background

The importance and complexity of handovers is well-established. Progress for intervening in the emergency department change of shift handovers may be hampered by lack of a conceptual framework. The objectives were to gain a better understanding of strategies used for change of shift handovers in an emergency care setting and to further expand current understanding and conceptualizations.

Methods

Observations, open-ended questions and interviews about handover strategies were collected at a Veteran's Health Administration Medical Center in the United States. All relevant staff in the emergency department was observed; 31 completed open-ended surveys; 10 completed in-depth interviews. The main variables of interest were strategies used for handovers at change of shift and obstacles to smooth handovers.

Results

Of 21 previously identified strategies, 8 were used consistently, 4 were never used, and 9 were used occasionally. Our data support ten additional strategies. Four agent types and 6 phases of the process were identified via grounded theory analysis. Six general themes or clusters emerged covering factors that intersect to define the degree of handover smoothness.

Conclusion

Including phases and agents in conceptualizations of handovers can help target interventions to improve patient safety. The conceptual model also clarifies unique handover considerations for the emergency department setting.

Gaps in pediatric clinician communication and opportunities for improvement

Teamwork and good communication are central to the provision of high-quality care. A standardized focus-group protocol was used. Analysis assessed emergent themes of patient safety-related effective and problematic clinician communication. Sixty-three focus groups were conducted with clinicians from five Chicago Pediatric Patient Safety Consortium hospitals. Effective and problematic clinician-to-clinician communication themes were described in all focus groups and at each participating hospital. Problematic communication contexts included the communication process for orders, consultations, acuity assessment, management of surgical and medical patients, and the discharge process. Organizational policies and systems leading to patient safety risk included a lack of clear responsibilities and expectations for clinicians and for clinical communication, as well as a lack of a clear chain of responsibility for communication when hierarchical communication barriers affected safe patient care. Results of this investigation highlighted gaps in pediatric clinician communication and opportunities for improvement.

A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience

INTRODUCTION

Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills.

AIM

To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills.

SETTING

Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center.

PROGRAM DESCRIPTION

We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team.

PROGRAM EVALUATION

We received 203 evaluations with a mean overall rating for the training of 4.49 +/- 0.79 on a 1-5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 +/- 0.68.

DISCUSSION

We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.

Where should hospitalists sit within the academic medical center?

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine's current trajectory and provide recommendations for hospital medicine's place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions.

Care transitions for hospitalized patients

Ensuring safe care transitions is a core part of hospital medicine. These transitions include inpatient-outpatient transitions and in-hospital transitions. To ensure safe care during these transitions, clinicians should be aware of the types of transitions and the way in which these transitions can impede safe patient care. With this knowledge, strategies to ensure patient safety during care transitions can be adopted and training directed at teaching physicians safe hands-off practices could be developed and supported.

Medication discrepancies in resident sign-outs and their potential to harm

BACKGROUND

The accuracy of information transferred during hand-offs is uncertain.

OBJECTIVE

To describe the frequency, types, and harm potential of medication discrepancies in resident-written sign-outs.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Internal Medicine interns and their patients at a single hospital in January 2006.

MEASUREMENTS

Daily written sign-outs were compared to daily medication lists in patient charts (gold standard). Medication discrepancies were labeled omissions (medication in chart, but not on sign-out) or commissions (medication on sign-out, but not in chart). Discrepancies were also classified as index errors (the first time an error was made) and the proportion of index errors that persisted on subsequent days. Using a modified classification scheme, discrepancies were rated as having minimal, moderate, or severe potential to harm.

RESULTS

One hundred eighty-six of 247 (75%) patients and 10 of 10(100%) interns consented. In the 165 (89%) patients' charts abstracted and compared with the sign-out, there were 1,876 of 6,942 (27%) medication chart entries that were discrepant with the sign-out with 80% (1,490/1,876) labeled omissions. These discrepancies originated from 758 index errors, of which 63% (481) persisted past the first day. Omissions were more likely to persist than commissions (68% [382 of 580] vs 53% [99 of 188], p < .001). Greater than half (54%) of index discrepancies were moderate or severely harmful. Although omissions were more frequent, commissions were more likely to be severely harmful (38% [72 of 188] vs 11% [65 of 580], p < .0001).

CONCLUSIONS

Written sign-outs contain potentially harmful medication discrepancies. Whereas linking sign-outs to electronic medical records can address this problem, current efforts should also emphasize the importance of vigilant updating in the many hospitals without this technology.

What Whiteboards in a Trauma Center Operating Suite Can Teach Us About Emergency Department Communication

STUDY OBJECTIVE

Highly reliable, efficient collaborative work relies on excellent communication. We seek to understand how a traditional whiteboard is used as a versatile information artifact to support communication in rapid-paced, highly dynamic collaborative work. The similar communicative demands of the trauma operating suite and an emergency department (ED) make the findings applicable to both settings.

METHODS

We took photographs and observed staff's interaction with a whiteboard in a 6-bed surgical suite dedicated to trauma service. We analyzed the integral role of artifacts in cognitive activities as when workers configure and manage visual spaces to simplify their cognitive tasks. We further identified characteristics of the whiteboard as a communicative information artifact in supporting coordination in fast-paced environments.

RESULTS

We identified 8 ways in which the whiteboard was used by physicians, nurses, and with other personnel to support collaborative work: task management, team attention management, task status tracking, task articulation, resource planning and tracking, synchronous and asynchronous communication, multidisciplinary problem solving and negotiation, and socialization and team building. The whiteboard was highly communicative because of its location and installation method, high interactivity and usability, high expressiveness, and ability to visualize transition points to support work handoffs.

CONCLUSION

Traditional information artifacts such as whiteboards play significant roles in supporting collaborative work. How these artifacts are used provides insights into complicated information needs of teamwork in highly dynamic, high-risk settings such as an ED.

Development and implementation of an oral sign-out skills curriculum

INTRODUCTION

Imperfect sign-out of patient information between providers has been shown to contribute to medical error, but there are no standardized curricula to teach sign-out skills. At our institution, we identified several deficiencies in skills and a lack of any existing training.

AIM

To develop a sign-out curriculum for medical house staff.

SETTING

Internal medicine residency program.

PROGRAM DESCRIPTION

We developed a 1-h curriculum and implemented it in August of 2006 at three hospital sites. Teaching strategies included facilitated discussion, modeling, and observed individual practice with feedback. We emphasized interactive communication, a structured sign-out format summarized by an easy-to-remember mnemonic ("SIGNOUT"), consistent inclusion of key content items such as anticipatory guidance, and use of concrete language.

PROGRAM EVALUATION

We received 34 evaluations. The mean score for the course was 4.44 +/- 0.61 on a 1-5 scale. Perceived usefulness of the structured oral communication format was 4.46 +/- 0.78. Participants rated their comfort with providing oral sign-out significantly higher after the session than before (3.27 +/- 1.0 before vs. 3.94 +/- 0.90 after; p < .001).

DISCUSSION

We developed an oral sign-out curriculum that was brief, structured, and well received by participants. Further study is necessary to determine the long-term impact of the curriculum.

Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety

OBJECTIVES

To identify the perceptions of emergency physicians (EPs) and hospitalists regarding interservice handoff communication as patients are transferred from the emergency department to the inpatient setting.

METHODS

Investigators conducted individual interviews with 12 physicians (six EPs and six hospitalists). Data evaluation consisted of using the steps of constant comparative, thematic analysis.

RESULTS

Physicians perceived handoff communication as a gray zone characterized by ambiguity about patients' conditions and treatment. Two major themes emerged regarding the handoff gray zone. The first theme, poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. Specifically, handoffs consisting of insufficient information, incomplete data, omissions, and faulty information flow exacerbated gray zone problems and may negatively affect patient outcomes. EPs and hospitalists had different expectations about handoffs, and those expectations influenced their interactions in ways that may result in communication breakdowns. The second theme illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Those interviewed talked about the systemic failures that lead to patient boarding and how poor handoffs exacerbated system flaws.

CONCLUSIONS

Handoffs between EPs and hospitalists both reflect and contribute to the ambiguity inherent in emergency medicine. Poor handoffs, consisting of faulty communication behaviors and conflicting expectations for information, contribute to patient boarding conditions that can pose safety threats. Pragmatic conclusions are drawn regarding physician-physician communication in patient transfers, and recommendations are offered for medical education.

The quality of communication about older patients between hospital physicians and general practitioners: a panel study assessment

Background

Optimal care of patients is dependent on good professional interaction between general practitioners and general hospital physicians. In Norway this is mainly based upon referral and discharge letters. The main objectives of this study were to assess the quality of the written communication between physicians and to estimate the number of patients that could have been treated at primary care level instead of at a general hospital.

Methods

This study comprised referral and discharge letters for 100 patients above 75 years of age admitted to orthopaedic, pulmonary and cardiological departments at the city general hospital in Trondheim, Norway. The assessments were done using a Delphi technique with two expert panels, each with one general hospital specialist, one general practitioner and one public health nurse using a standardised evaluation protocol with a visual analogue scale (VAS). The panels assessed the quality of the description of the patient's actual medical condition, former medical history, signs, medication, Activity of Daily Living (ADL), social network, need of home care and the benefit of general hospital care.

Results

While information in the referral letters on actual medical situation, medical history, symptoms, signs and medications was assessed to be of high quality in 84%, 39%, 56%, 56% and 39%, respectively, the corresponding information assessed to be of high quality in discharge letters was for actual medical situation 96%, medical history 92%, symptoms 60%, signs 55% and medications 82%. Only half of the discharge letters had satisfactory information on ADL. Some two-thirds of the patients were assessed to have had large health benefits from the general hospital care in question. One of six patients could have been treated without a general hospital admission. The specialists assessed that 77% of the patients had had a large benefit from the general hospital care; however, the general practitioners assessment was only 59%. One of four of the discharge letters did not describe who was responsible for follow-up care.

Conclusion

In this study from one general hospital both referral and discharge letters were missing vital medical information, and referral letters to such an extent that it might represent a health hazard for older patients. There was also low consensus between health professionals at primary and secondary level of what was high benefit of care for older patients at a general hospital.

Patient safety in women's health care: a framework for progress

Patient safety research is hampered by lack of a clear taxonomy and difficulty in detecting errors. Preventable adverse events occur in medicine because of human fallibility, complexity, system deficiencies and vulnerabilities in defensive barriers. To make medicine safer there needs to be a culture change, beginning with the leadership. Latent systems deficiencies must be identified and corrected before they cause harm. Defensive barriers can be improved to intercept errors before patients are harmed. Strategies include: (1) providing leadership at all levels; (2) respecting human limits in equipment and process design; (3) functioning collaboratively in a team model with mutual respect; (4) creating a learning environment where errors can be analyzed without fear of retribution; and (5) anticipating the unexpected with analysis of high-risk processes and well-designed contingency plans. The ideal of a 100% safe health-care system is unattainable, but there must be continual improvement.

Communication failure: basic components, contributing factors, and the call for structure

BACKGROUND

Communication is a taken-for-granted human activity that is recognized as important once it has failed. Communication failures are a major contributor to adverse events in health care.

BASIC COMMUNICATION COMPONENTS AND PROCESSES

The components and processes of communication converge in an intricate manner, creating opportunities for misunderstanding along the way. When a patient's safety is at risk, providers should speak up (that is, initiate a message) to draw attention to the situation before harm is caused. They should also clearly explain (encode) and understand (decode) each other's diagnosis and recommendations to ensure well coordinated delivery of care.

INDIVIDUAL, GROUP, AND ORGANIZATIONAL FACTORS

Beyond basic dyadic communication exchanges, an intricate web of individual, group, and organizational factors--more specifically, cognitive workload, implicit assumptions, authority gradients, diffusion of responsibility, and transitions of care--complicate communication.

THE CALL FOR STRUCTURE

More structured and explicitly designed forms of communication have been recommended to reduce ambiguity, enhance clarity, and send an unequivocal signal, when needed, that a different action is required. Read-backs, Situation-Background-Assessment-Recommendation, critical assertions, briefings, and debriefings are seeing increasing use in health care. CODA: Although structured forms of communication have good potential to enhance clarity, they are not fail-safe. Providers need to be sensitive to unexpected consequences regarding their use.

Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors

OBJECTIVES

To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs.

METHODS

A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency and pediatric EM fellowship program was conducted in March 2006.

RESULTS

Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error.

CONCLUSIONS

There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.

Design and implementation of an ICU incident registry

Due to its complexity intensive care is vulnerable to errors. On the ICU adults of the AMC (Amsterdam, The Netherlands) the available registries used for error reporting did not give insight in the occurrence of unwanted events, and did not lead to preventive measures. Therefore, a new registry has been developed on the basis of a literature study on the various terms and definitions that refer to unintended events, and on the methods to register and monitor them. As this registry intends to provide an overall insight into errors, a neutral term ('incident') -- which does not imply guilt or blame -- has been sought together with a broad definition. The attributes of an incident further describe the unwanted event, but they should not form an impediment for the ICU nurses and physicians to report. The properties of a registry that contribute to making it accessible and user friendly have been determined. This has resulted in an electronic registry where incidents can be reported rapidly, voluntarily, anonymously and free of legal consequences. Evaluation is required to see if the new registry indeed provides the ICU management with the intended information on the current situation on incidents. For further refinement of the design, additional development and adjustments are required. However, we expect that the awareness of errors of the ICU personnel has already improved, forming the first step to increased patient safety.

A model for building a standardized hand-off protocol

BACKGROUND

The Joint Commission has made a "standardized approach to hand-off communications" a National Patient Safety Goal.

METHOD

An interactive 90-minute workshop (hand-off clinic) was developed in 2005 to (1) develop a standardized process for the handoff, (2) create a checklist of critical patient content, and (3) plan for dissemination and training.

CONCLUSION

To date, 7 of 10 residency programs have participated. Analysis of these protocols demonstrated that the hand-off process is highly variable and discipline-specific. Although all disciplines required a verbal handoff, because of competing demands, verbal communication did not always occur. In some cases, the transfer of professional responsibility was separated in time and space from the transfer of information. For example, in two cases, patient tasks were assigned to other team members to facilitate timely departure of a postcall resident (to meet resident duty-hour restrictions), but results were not formally communicated to anyone. The hand-off clinic facilitated the incorporation of "closed-loop" communication by requiring that follow-up on these tasks be conveyed to the on-call resident.

DISCUSSION

This model for design and implementation can be applied to other health care settings.