Patient handoff must be more than a formality
Patient handoff is a high-risk time that many health care workers don’t handle as well as they should, cautions Meghan Dierks, MD, MS, a faculty member at Harvard Medical School and a member of the Clinical Decision Making Group at the Massachusetts Institute of Technology, both in Cambridge.
As a surgeon who focuses on human factors, systems, and patient safety, Dierks has studied patient handoffs extensively.
Her expertise especially is useful now that the Joint Commission on Accreditation of Healthcare Organizations’ 2006 National Patient Safety Goals include a new requirement for safely handing off patients from one caregiver to another.
The Joint Commission will require that handoffs of patients between caregivers be standardized, with particular attention to assuring the opportunity for asking and responding to questions. That requirement is part of the Goal: "Improve the effectiveness of communication among caregivers."
Dierks says the Joint Commission is drawing needed attention to a common situation that puts patients at risk.
When the handoff is not done well, crucial information can be missed and caregivers can make mistaken assumptions.
Not just a data transfer
The most common flaw in patient handoffs is the tendency to view it as a "data transfer rather than a higher level information exchange," she notes.
Instead, the handoff should be "an exchange of very complex, abstract information." For instance, the outgoing caregiver should discuss how the patient’s status is or is not consistent with the expected.
Caregivers should contextualize the information at handoff, "to give the receiver the ability to anticipate problems — to understand where the patient is on a trajectory and not just at this one point in time," she says.
Staff and physicians also should explain the patient’s anticipated progress at handoff. For instance, outgoing caregivers should explain what they anticipate to be the immediate progress of the patient. Also, what are the contingency plans? How will the patient’s treatment change if certain events play out?
Info often doesn’t register
Dierks has spent a lot of time observing patient handoffs, and she reports some interesting conclusions.
First, she says, the quality of a patient handoff declines as more people are involved. Often the caregivers who are handing the patient off will provide conflicting information to the person receiving the patient, yet that person never acknowledges the conflict or asks for clarification.
"They just let it go," she says. "That suggests that the recipient wasn’t really processing the information, either because they didn’t have the time or they didn’t see that as their role. Instead they just rapidly wrote down these data points."
Dierks recommends formalizing the handoff process rather than allowing it to be an ad-hoc, on-the-fly occurrence. She suggests risk managers help educate staff, physicians, and department heads about the importance of a good handoff, and how to do it.
"A lot of times, people will agree with you when you say that handoffs aren’t what they should be, but they just don’t have a good idea of how to improve them," she adds. "That’s where you can help by showing them what information needs to be conveyed and how to make sure they’re actually having a dialogue instead of just passing data to each other."
Dierks suggests risk managers start by going to different departments, such as the intensive care unit, and asking the staff how well handoffs currently work. Do they have to go back later and track down needed information? Are there constraints that make it difficult to effectively discuss a patient’s condition?
Though it might be tempting to create a standardized handoff form with this information, she advises against that tactic. Any type of standardized way for handing off patients, whether it’s on paper or electronic, tends to pre-define what elements of the report are important. That exacerbates the common problems of handoffs being "data transfers" rather than meaningful discussions about the patient’s status and treatment.
However, Dierks does offer an outline of what information will be discussed in an ideal patient handoff. (For the outline, see p. 94.)
Patient handoff is a high-risk time that many health care workers dont handle as well as they should, cautions Meghan Dierks, MD, MS, a faculty member at Harvard Medical School and a member of the Clinical Decision Making Group at the Massachusetts Institute of Technology, both in Cambridge.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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