Hospitalists & Handoffs

Use Redundancy and Simulation to Improve Safety

Given the clear challenges of providing quality and continuity of care in the inpatient setting, hospitalists are well positioned to identify strategies for safe and effective patient handoffs and advocate for a systems approach to their implementation.

Safety strategies that have been employed by industries outside of healthcare can provide a useful starting point. So-called “highly reliable” organizations use a variety of approaches to reduce the incidence of errors that occur during transitions in work staff. A recent review of transition methods used by NASA’s Johnson Space Center (Houston), Canadian nuclear power plants, and an ambulance dispatch center—organizations where lapses in transitions also have serious consequences—found that these entities used up to 21 handoff strategies.10 Techniques included verbal, face-to-face, and interactive questioning coordinated with written summaries just before a shift change.

Increasing redundancy is another technique used by highly reliable organizations to reduce the likelihood of missed, incomplete, or misinterpreted information. To create redundancy in clinical care, a physician would include more information at the outset of a procedure or medication order than is now typically provided. This additional information is then repeated and validated by other members of the care team throughout the process, reducing the likelihood of misinterpretation of an instruction or action based on incomplete information.

For example, if a physician always includes both the drug name and the condition for which it is prescribed, a medication order for “Celebrex, seizures,” instead of “Cerebyx, seizures,” would immediately indicate a mistake had occurred in ordering a pain medication instead of an anti-convulsant.11 Research has shown that increasing the amount of information about a medication order reduces the range of potentially valid clinical decisions.

Whether a hospital relies on verbal communication, written communication, computer-based communication, or a combination of all three, redundancy can be built into its sign-out processes. As PDAs become more widely used, structured sign-outs should incorporate redundancy into patient-specific checklists to include information on clinical status, recent and pending tests and study results, and similar, pertinent information.

Simulation-based training that incorporates redundancy and promotes read-back of patient information holds promise for error reduction, especially during patient handoffs.

AHRQ has recently funded research on simulation training projects that seek to:

• Reduce communication errors during patient handoffs in the emergency department by implementing a patient-specific checklist based on an electronic medical record and by testing the effect of companion simulation-based training; and
• Evaluate and improve safe communication and coordination between anesthesia providers and nurses during care transitions and during hand-offs between the operating room and the post-anesthesia care unit.12

The 24/7 role of hospital physicians brings unique experiences and insights to the challenges of patient safety that can test the feasibility of systems to reduce errors associated with care transitions. As their numbers and leadership roles expand, hospitalists are poised to make significant contributions to improving patient safety and outcomes.

We at AHRQ look forward to assisting hospitalists in making these contributions and to achieving these goals together. We also look forward to continuing our relationship with SHM and the hospitalist community as a whole. TH

Dr. Clancy is the director of the Agency for Healthcare Research and Quality.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996 Aug 15;335(7):514-517.
2. Impact of the nation’s hospitalists continues to grow new society of hospital medicine survey says [press release]. Society of Hospital Medicine. May 4, 2006.
3. Society of Hospital Medicine. The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med. 2006;1;S1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.72/pdf. Last accessed January 17, 2007.
4. Vidyarthi A [commentary]. Agency for Healthcare Research and Quality Web M&M: Morbidity and Mortality Rounds on the Web. Fumbled handoff. March 2004. Available at: www.webmm.ahrq.gov/case.aspx?caseID=55. Last accessed January 17, 2007.
5. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land LLG; 2004.
6. Vidyarthi A. Morbidity and Mortality Rounds on the Web, “Fumbled Handoff,” unpublished data, 2004.
7. Biller CK, Antonacci AC, Pelletier S, et al. The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res. 2006 Oct;135(2):275-281. Epub 2006 Aug 24.
8. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med. 1996;11(12):753-755.
9. O’Leary KJ, Leibovitz DM, Feinglass J, et al. Outpatient physicians’ satisfaction with discharge summaries and perceived need for an electronic discharge summary. J Hosp Med. 2006;1:317-320. Published online Oct. 11, 2006.
10. Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Company; 1997:135.
11. Bar-Yam Y. System care: multiscale analysis of medical errors–eliminating errors and improving organizational capabilities. New England Complex Systems Institute: Technical Report; Sept 2004. Available at: http://necsi.org/projects/yaneer/NECSITechnicalReport2004-09.pdf. Last accessed January 17, 2007.
12. Agency for Healthcare Research and Quality. Improving patient safety through simulation research. 2006 Simulation Projects. Available at: www.ahrq.gov/qual/simulproj.htm. Last accessed January 17, 2007.