The Danger of Handoffs

72991367Handoffs, or to wax PC, handovers, are those circumstances where the person who's been managing a patient during a particular time period in the hospital meets with those just coming on to the unit and recites what's been done, current status, medications and so on relative to the patient's care as they end their shift. As Rick and I discuss on PodMed this week, and as published in a study in JAMA Internal Medicine, this is prime time for medical errors, some of which could seriously compromise patient care.  And as Rick laments on the podcast, this problem has been recognized for some time in academic medicine but has so far proven quite resistant to attempted remedies.  What did they do here?

Investigators tagged along on morning handover in two tertiary care academic medical centers in Toronto, Canada, on the general internal medicine service. Medical care on these services is provided during the day by a team consisting of one attending physician, one senior resident, at least two interns, and two medical students. At night an on-call trainee provides care, and this is usually a member of the daytime team but may be a trainee from another service or team.  Electronic medical records are employed in both centers but notes by both physicians and nurses occur on paper. The verbal handover process is supported by an Internet-based written sign out tool.

The researcher took notes during morning handover and in particular the occurrence of interruptions or distractions during the process. Each case was reviewed by investigators and pertinent data and notes by care providers integrated. Data from 26 observations revealed that  "The on-call trainee did not verbally hand over 40.4% (95% CI, 32.3%-48.5%) of the clinically important overnight issues and did not document a progress note for 85.8% (95% CI, 80.1%-91.6%) of these issues. Trainees documented 7.8% (95% CI, 3.4%-12.2%) of clinically important issues in the Internet-based written sign-out tool. There were 52 (36.9%; 95% CI, 28.9%-44.8%) clinically important issues that were neither handed over nor documented by the on-call trainee."

Wow.  That's a lot of important information relevant to a patient's care that wasn't revealed in the handoff, and didn't appear elsewhere either. Factors that may have contributed include the following: "Handover took place in many different locations in the hospital  and occurred in a dedicated team room only 41% of the time. Teams divided the handover process into more than 1 encounter 68% of the time (eg, handover of overnight issues occurred before and after morning teaching rounds). Teams met for a mean total of 71 (26) minutes to review new cases and hand over overnight issues. Teams spent most of their time reviewing new information on patients admitted during the previous night, with a mean of only 11 (10) minutes dedicated to handing over on-call overnight issues. During these interactions, teams experienced 6.1 (7.1) distractions per hour resulting in 2.6 (2.9) interruptions per hour."  As Rick opines in the podcast, these findings point to clear ways to redesign the process to help minimize the errors, while I assert that this is clearly a place where family or loved ones can help support the team in providing care by also reviewing the chart, medications, tests and so forth.  Seems a likely place where substantial improvements can be made.

Other topics this week include catheter-based thrombolysis for deep vein thrombosis in the same journal, morcellation and uterine fibroids in JAMA, and a new pathway identified in antiphospholipid antibody syndrome in NEJM.  Until next week, y'all live well.

 

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Randy Goldberg MD MPH FACP July 26, 2014 at 6:28 am

I'm glad to notice that our program (Internal Medicine, New York Medical College at Westchester Medical Center) avoids most of these errors. Handoffs occur in a dedicated room. Afternoon handoffs are supervised by a chief resident, and morning handoffs are supervised by a chief or the Program Director. Only handoffs are discussed; new admissions are presented separately. We use an electronic handoff system; in fact, it's available via handheld device, and no paper is used. The electronic handoffs are reviewed by the relevant hospitalist in the afternoon, before the handoff is actually made, to ensure correctness and completeness.

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Elizabeth Tracey July 28, 2014 at 9:54 am

Wow! Congratulations on already spying these problems and implementing a solution. I'm glad to give you a space to tell more about it, and thank you for writing.

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