Enhancing Patient Safety During Hand-Offs
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Few institutions have systems in place to insure that information is accurately and completely transferred between house staff during sign-offs.
Source: Horwitz LI, et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173-1177.
Transfers of care can be problematic if critical information is not shared when responsibility transitions between clinicians. Although such "hand-offs" create the opportunity for error, transfer management in United States hospitals has never been described on a national level. To better characterize the systems in place, Horwitz and colleagues identified all accredited internal medicine residency programs in the United States and surveyed chief residents in 324 programs. The sample excluded 62 programs. Of these, 60 were located in New York (more stringent regulations) and 2 were newly established. A transfer of care was defined as a time at which immediate responsibility for a patient was passed from one physician to another, excluding short-term transfers, eg, clinic coverage. Surveys were completed by 62% of the eligible programs. There were no statistically significant demographic differences between respondents and non-respondents.
Transfer systems varied among and within institutions: 55% did not consistently require both a written and oral sign-out at transfers of care, 34% left sign-out to interns alone, and 59% had no formal means of informing nurses that a transfer of care had taken place. The majority (60%) of programs did not provide any lectures or workshops on sign-out skills. Most programs with written sign-outs used low technology formats; only 14% used a web-based or clinical information system-based sign-out system.
Commentary
Findings of this study suggest that few internal medicine trainees receive formal instruction, supervision, or feedback in the "handoff" process. The time when care is transferred from one management team to another, known as "hand-offs," represents a high-risk interval. Important details about the patient's history and management may be lost if they are not included in the report or accurately recalled. This is a critical issue because failures in communication have been implicated as threats to patient safety in several studies.
Several solutions have been proposed to improve this process, ranging from low- to high-tech solutions. Low-tech solutions include taking steps to insure that formal content is included in training programs and structuring schedules to minimize transfers. High-tech solutions include systems that insure pager forwarding and computerized sign-outs that automatically incorporate accurate and up-to-date information. Few of these approaches have been subjected to systematic evaluation and a high-tech solution cannot substitute for effective verbal communication.
One additional solution that can be easily adapted involves use of the Situational Debriefing Model, known as SBAR (Situation, Background, Assessment, and Recommendation). This model was developed and successfully used by the United States Navy to insure that critical information is communicated in a timely and orderly fashion. Situation and background are objective components; assessment and recommendation allow delivery of subjective information, coupled with a request for a specific intervention. A particular advantage of this tool is that it creates redundancy and, thereby, establishes an expected pattern of communication. When there is deviation from the pattern, the omission becomes more apparent.
SBAR can help overcome different communication styles, eg, clinicians who give long descriptive reports vs those who request "the headlines." There is also evidence that SBAR can reduce adverse events related to hand-offs. OSF St. Joseph Medical Center implemented SBAR using pocket cards and laminated "cheat sheets" posted at each phone. The briefing format was used by more than 98% of nurses and credited with reducing the rate of adverse events from 39.6 to 89.9 per 1,000 patient days.1
Reference
- Landro L. Hospitals Combat Errors at the "Hand-Off." The Wall Street Journal. June 26, 2006:D1-2.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content