Original ContributionED handoffs: observed practices and communication errors☆,☆☆
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.
References (34)
- et al.
Simple standardized patient handoff system that increases accuracy and completeness
J Surg Educ
(2008) - et al.
The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care
Int J Med Inform
(2007) - et al.
Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk
Chest
(2008) - et al.
A model for building a standardized hand-off protocol
Jt Comm J Qual Patient Saf
(2006) - et al.
The effect of clinical experience on the error rate of emergency physicians
Ann Emerg Med
(2008) Patient safety in American hospitals, July 2004
- et al.
Handoffs causing patient harm: a survey of medical and surgical housestaff
Jt Comm J Qual Patient Saf
(2008) National patient safety goals: hospital
- et al.
Handoff strategies in seetings with high consequences for failure: lessons for health care operations
Int J Qual Health Care
(2004)
Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs
Acad Med
Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors
Acad Emerg Med
Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
Qual Saf Health Care
Improving handoffs through better communication. ACP Hospitalist, July 2009
Readback hearback. Aviation safety reporting system directline, March 1991
Medicine-related problems resulting in emergency department visits
Eur J Clin Pharmocol
Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward
Teach Learn Med
Cited by (64)
So Many Ways to Be Wrong: Completeness and Accuracy in a Prospective Study of OR-to-ICU Handoff Standardization
2023, Joint Commission Journal on Quality and Patient SafetyOptimizing Pediatric Patient Safety in the Emergency Care Setting
2022, Journal of Emergency NursingComparison of a formatted versus traditional sign out process for physicians in the emergency department
2022, American Journal of Emergency MedicineHandoffs and Teamwork: A Framework for Care Transition Communication
2022, Joint Commission Journal on Quality and Patient SafetyIn reply:
2019, Annals of Emergency MedicineWaterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department
2019, Annals of Emergency MedicineCitation Excerpt :The risks associated with handoffs have been well documented.1-3
- ☆
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.