Standardizing Shift-to-Shift Patient Handoffs Could Reduce Medical Errors

Tuesday, August 9th, 2011
This post was written by Patricia Donovan

Faulty or incomplete handoffs of patients between provider shifts in teaching hospitals may be responsible for more medical errors occurring in hospitals than overworked, sleep-deprived medical residents, suggests an article in the August 7, 2011 New York Times Magazine.

The solution may be startingly simple: adopt a universal patient handoff protocol and train the entire staff in its use.

Author Darshak Sanghavi points to a small but significant pilot conducted at Boston’s Children’s Hospital, in which the shift-to-shift patient handoff process was standardized: computerized patient summaries were created and used, a structured verbal handoff was developed, and hospital staff was trained in all aspects of the initiative. At the end of the three-month pilot, medical errors among this pediatric population had dropped 40 percent.

This pilot has tremendous implications for an issue that has become a major focus of the healthcare industry. For the last few years, healthcare organizations have been working to tighten transitions between care sites, such as from hospital to home or hospital to skilled nursing facility. This management is principally the responsibility of a dedicated case manager, who is charged with the ultimate goal of reducing hospital readmissions and ER visits, particularly by high-utilizing Medicare beneficiaries.

While the bulk of efforts to improve patient handoffs are aimed at new young doctors, it makes sense that shift-to-shift patient handoff protocols should be examined and standardized in tandem with site-to-site patient transitions in any initiative to improve care transitions, such as the CMS Community-Based Care Transitions Program.

The numerous discussions of care transition management strategies hosted by the Healthcare Intelligence Network over the last few years have mainly focused on site-to-site transfers of patients rather than handoffs of patients between shifts of providers. However, more recently in the case management arena, we are hearing more about the “daily huddle” at the physician practice level.

The results of a study reported in the Association of Program Directors in Surgery’s Journal of Surgical Education also found that simplifying and standardizing the instrument used for patient handoffs improved resident perceptions of accuracy, completeness, and number of tasks transferred.

Also, an article in the November 2007 issue of infocus, The Quarterly Journal for Health Care Practice and Risk Management, described several tools in use around the country to standardize patient handoffs. “Handoff Communications: Heeding the Call to Change,” reports on a range of sign-out systems designed to help ensure safe handoffs at shift changes.

Have you reduced medical errors and/or avoidable utilization by standardizing internal patient handoff protocols? Please share any tools you have developed in this area.

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