Original Contribution
ED handoffs: observed practices and communication errors,☆☆

https://doi.org/10.1016/j.ajem.2009.12.004Get rights and content

Abstract

Objective

The study objectives were to identify emergency department (ED) handoff practices and describe handoff communication errors among emergency physicians.

Methods

Two investigators observed patient handoffs among emergency physicians in a major metropolitan teaching hospital for 8 weeks. A data collection form was designed to assess handoff characteristics including duration, location, interruptions, and topics including examination, laboratory examinations, diagnosis, and disposition. Handoff errors were defined as clinically significant examination or laboratory findings in physician documentation that were reported significantly differently during or omitted from verbal handoff. Multivariate negative binomial regression models assessed variables associated with these errors. The study was approved by the institutional review board.

Results

One hundred ten handoff sessions encompassing 992 patients were observed. Examination handoff errors and omissions were noted in 130 (13.1%) and 447 (45.1%) handoffs, respectively. More examination errors were associated with longer handoff time per patient, whereas fewer examination omissions were associated with use of written or electronic support materials. Laboratory handoff errors and omissions were noted in 37 (3.7%) and 290 (29.2%) handoffs, respectively. Fewer laboratory errors were associated with use of electronic support tools, whereas more laboratory handoff omissions were associated with longer ED lengths of stay.

Conclusions

Clinically pertinent findings reported in ED physician handoff often differ from findings reported in physician documentation. These errors and omissions are associated with handoff time per patient, ED length of stay, and use of support materials. Future research should focus on ED handoff standardization protocols, handoff error reduction techniques, and the impact of handoff on patient outcomes.

Introduction

Poor communication is recognized as a major factor contributing to the estimated 44 000 to 195 000 patient deaths that occur each year due to medical error [1], [2]. Patient handoffs between physicians are recognized as a time of potential communication lapses that leads to errors in patient care. Fifty-nine percent of medical and surgical residents in a recent study reported that one or more of their patients were harmed as a result of inadequate handoffs [3]. In an effort to reduce handoff errors and resultant medical errors, the Joint Commission has made implementation of a standardized approach to handoff communications a Hospital National Patient Safety Goal [4].

There is perhaps no area in the hospital with a greater number of handoffs than the emergency department (ED). Multiple handoffs occur each shift between nurses, physicians, and ancillary staff, as well as between ED personnel and other hospital personnel during patient testing, imaging, and admission processing. In addition, shift work necessitates patient handoffs at the end of every shift. These handoffs often involve unstable patients with high-acuity illness. In spite of the frequency of handoffs and despite the use of established handoff strategies in other high-risk industries, standardized protocols or guidelines for transfer of care of patients in the ED are not yet in place [5], [6]. Almost 90% of ED residency directors answering a recent survey reported no existing uniform patient handoff policy [7].

The objectives of this study are to describe ED physician handoff practices and quantify handoff communication errors.

Section snippets

Study design

This was a prospective observational study of ED handoffs conducted at an urban, public teaching hospital with an annual ED census of approximately 91 000 patients. The ED is a 72-bed unit with an additional 14 beds devoted to an observation unit. The study protocol was approved by the institutional review board through expedited review, with a waiver of the requirement of written informed consent.

Data collection tool

To guide the development of our data collection form, we developed a short questionnaire regarding

Handoff observation

One hundred ten physician-to-physician handoff sessions were observed for a total of 992 patient handoffs. Seventy-three (7%) handoffs were between resident physicians only, 779 (79%) were between attending physicians only, and 140 (14%) included both in group handoffs. Most resident handoffs were among senior residents. All observed handoffs were face-to-face exchanges among physicians. Nurses did not participate in any observed handoffs. The average attending handoff session included 10.4

Discussion

This study identified emergency physician handoff practices and communication errors through direct observation. During the handoff observation period, we were able to quantify handoff communication errors and to identify variables independently associated with handoff communication errors. Measuring patient outcomes associated with handoff errors was beyond the scope of this project.

Omission of physical examination findings was common, as 40% of handoffs included no physical examination

Limitations

This study has several limitations. First, we observed physicians in a single institution without a standardized handoff protocol, and thus, our findings may not be generalizable to all institutions. Second, physicians were classified as residents or attendings but were not further stratified within those groups by their level of experience. Recent literature suggests that attending EM physicians with limited experience may commit errors more often than those with more experience [34].

Conclusions

Clinically pertinent findings reported in ED physician handoff often differ from findings reported in chart notes. These communication errors are associated with handoff time per patient, ED length of stay, and use of support materials. Future research should focus on ED handoff standardization protocols, error-reduction techniques in handoffs, and the impact of ED handoff errors on patient outcomes.

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    Research site: MetroHealth Medical Center, Department of Emergency Medicine, 2500 MetroHealth Drive, Cleveland, Ohio 44109.

    ☆☆

    Prior presentation poster at SAEM 2008 Annual Meeting, May 29-June 1, 2008, Washington, DC.

    1

    Previous affiliation: Case Western Reserve University School of Medicine, Cleveland, Ohio.

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