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Triple Hand Off
PERIOPERATIVE GRAND ROUNDS Triple Hand Off The Case: An 83-year-old man with a history of paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for placement of a permanent pacemaker. The patient underwent the procedure via the left subclavian vein at 2:30 PM. A routine postoperative radiograph showed no pneumothorax. At 5 PM, the patient stated he was short of breath and complained of new left-sided back pain. The nurse noted that the patient’s pulse oxygenation had dropped from 95% to 88%. The nurse started supplemental oxygen and asked the covering intern to see the patient. The intern, who had never met the patient, examined him and found him feeling better, with improved oxygenation. The nurse suggested that another radiograph be taken because of the recent surgery. The intern concurred, and a second radiograph was taken at 6 PM. An hour later, the nurse asked the intern if he had seen the radiograph yet. The intern stated that he was handing off the radiograph to the night resident who would be in at 8 PM. Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10 PM, the nurse still had not heard anything about the radiograph so he contacted the night resident. The resident was busy but promised to look at the radiograph and advise the nurse if there was any problem. Finally, at midnight, when the nurse handed off the patient to
the night shift nurse, he mentioned the patient’s symptoms and noted the night resident had not called back to report any problems. The next morning, the radiologist read the second radiograph and noted a large left pneumothorax. A cardiothoracic surgeon was consulted, and a chest tube was placed at 2:30 PM, more than 20 hours after the second radiograph was performed. The team subsequently learned that the night resident had mistakenly examined the radiograph taken immediately after surgery rather than the second chest radiograph and, therefore, did not see the film with the large pneumothorax. Luckily, the patient had no long-lasting harm from the delay.
Discussion: In this case, important information was lost because of hand offs of patient care responsibility from one practitioner to another, and this resulted in diagnosis and treatment delay and a near-miss error. This patient’s experience of discontinuous care is not uncommon in hospitals today. Regulatory duty-hour mandates have increased the number of hand offs in teaching hospitals.1 When considering that 16.9 million patients are admitted to teaching hospitals each year, the number of hand offs is staggering.2 Most hand-off errors are “content omissions” in which critical information is not communicated.3,4 (continued on page 436)
This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Arpana R. Vidyarthi, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Vidyarthi AR. Triple Handoff. AHRQ WebM&M [serial online]. September 2006. http://www.webmm.ahrq.gov/case.aspx?caseID⫽134. Accessed August 3, 2010.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
doi: 10.1016/j.aorn.2010.07.009
490
AORN Journal ●
October 2010
Vol 92
No 4
© AORN, Inc, 2010
October 2010
Vol 92
(continued from page 490) One solution to mitigate patient harm is to standardize the hand-off procedure.1,5,6 for all health care providers. The Joint Commission National Patient Safety Goal 02.05.01 requires all health care providers to “implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions.”7 Elements of an effective written hand off include accurate administrative information about the patient (ie, name, location); a brief history and diagnosis; medications; current status and severity of the illness; recent procedures and significant events; tasks that need to be completed; and contingency plans for any anticipated problems (ie, previously effective therapeutic interventions). Computerized templates that specify categories of information necessary for the hand off could facilitate the standardization of written content. Face-to-face verbal communication adds value to the hand off.8 Verbal hand-off reports must be tailored to the needs and skills of the recipient. For example, a less-experienced health care provider or one who is new to the patient may require more information than an experienced health care provider or one who is familiar with the patient. Verbal hand offs should take place in a designated area, as free from distractions and interruptions as possible, with access to written up-to-date information. The information communicated should be structured and consistent in format and include the same elements as the written hand off. The receiver of the hand off should repeat back information about tasks that need to be completed for the patient. Implementing these changes may seem relatively easy, but it is not, even with the most advanced electronic health record and the availability of experts.9 Fortunately, many facility administrators, having recognized the consequences of poor hand offs on care quality and safety, now seem ready to make improvements. Hand offs are a reality of patient care in today’s hospitals. Each hand off introduces risk, so using a systematic method to transfer information can improve the processes for hand offs, thereby reducing the potential for error. AORN, in collaboration with the US
436
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PERIOPERATIVE GRAND ROUNDS
No 4
Department of Defense Patient Safety Program, developed the Perioperative Patient “Hand-off” Tool Kit, which is available free to members on AORN’s web site.10
Perioperative Points:
Hand offs occur at least three times for any surgical patient, placing patients at risk for errors because of discontinuity of care. Structured hand-off systems, including verbal and written standards, can improve the effectiveness of the process. Ideally, these structures will be integrated into an electronic health record. All members of the health care team should use the same hand-off process for each patient to help standardize care and promote safer patient transfer between health care providers.
References 1.
2.
3.
4. 5.
6.
7.
8.
9.
10.
Vidyarthi A, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257-266. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. http:// hcupnet.ahrq.gov. Accessed August 6, 2010. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. Nolan TW. System changes to improve patient safety. BMJ. 2000;320(7237):771-773. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physicianto-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. Safe Handover: Safe Patients. London, England: British Medical Association; August 2004. http://www .bma.org.uk/images/safehandover_tcm41-20983.pdf. Accessed August 6, 2010. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/PatientSafety/National PatientSafetyGoals. Accessed August 6, 2010. Ambler SW. Communication on agile software projects. http://www.agilemodeling.com/essays/communication. htm. Accessed August 6, 2010. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351(18):1838-1848. Perioperative Patient “Hand-Off” Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources/ToolKits/ PatientHandOffToolKit. Accessed August 6, 2010.
the night shift nurse, he mentioned the patient’s symptoms and noted the night resident had not called back to report any problems. The next morning, the radiologist read the second radiograph and noted a large left pneumothorax. A cardiothoracic surgeon was consulted, and a chest tube was placed at 2:30 PM, more than 20 hours after the second radiograph was performed. The team subsequently learned that the night resident had mistakenly examined the radiograph taken immediately after surgery rather than the second chest radiograph and, therefore, did not see the film with the large pneumothorax. Luckily, the patient had no long-lasting harm from the delay.
Discussion: In this case, important information was lost because of hand offs of patient care responsibility from one practitioner to another, and this resulted in diagnosis and treatment delay and a near-miss error. This patient’s experience of discontinuous care is not uncommon in hospitals today. Regulatory duty-hour mandates have increased the number of hand offs in teaching hospitals.1 When considering that 16.9 million patients are admitted to teaching hospitals each year, the number of hand offs is staggering.2 Most hand-off errors are “content omissions” in which critical information is not communicated.3,4 (continued on page 436)
This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Arpana R. Vidyarthi, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Vidyarthi AR. Triple Handoff. AHRQ WebM&M [serial online]. September 2006. http://www.webmm.ahrq.gov/case.aspx?caseID⫽134. Accessed August 3, 2010.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
doi: 10.1016/j.aorn.2010.07.009
490
AORN Journal ●
October 2010
Vol 92
No 4
© AORN, Inc, 2010
October 2010
Vol 92
(continued from page 490) One solution to mitigate patient harm is to standardize the hand-off procedure.1,5,6 for all health care providers. The Joint Commission National Patient Safety Goal 02.05.01 requires all health care providers to “implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions.”7 Elements of an effective written hand off include accurate administrative information about the patient (ie, name, location); a brief history and diagnosis; medications; current status and severity of the illness; recent procedures and significant events; tasks that need to be completed; and contingency plans for any anticipated problems (ie, previously effective therapeutic interventions). Computerized templates that specify categories of information necessary for the hand off could facilitate the standardization of written content. Face-to-face verbal communication adds value to the hand off.8 Verbal hand-off reports must be tailored to the needs and skills of the recipient. For example, a less-experienced health care provider or one who is new to the patient may require more information than an experienced health care provider or one who is familiar with the patient. Verbal hand offs should take place in a designated area, as free from distractions and interruptions as possible, with access to written up-to-date information. The information communicated should be structured and consistent in format and include the same elements as the written hand off. The receiver of the hand off should repeat back information about tasks that need to be completed for the patient. Implementing these changes may seem relatively easy, but it is not, even with the most advanced electronic health record and the availability of experts.9 Fortunately, many facility administrators, having recognized the consequences of poor hand offs on care quality and safety, now seem ready to make improvements. Hand offs are a reality of patient care in today’s hospitals. Each hand off introduces risk, so using a systematic method to transfer information can improve the processes for hand offs, thereby reducing the potential for error. AORN, in collaboration with the US
436
AORN Journal
PERIOPERATIVE GRAND ROUNDS
No 4
Department of Defense Patient Safety Program, developed the Perioperative Patient “Hand-off” Tool Kit, which is available free to members on AORN’s web site.10
Perioperative Points:
Hand offs occur at least three times for any surgical patient, placing patients at risk for errors because of discontinuity of care. Structured hand-off systems, including verbal and written standards, can improve the effectiveness of the process. Ideally, these structures will be integrated into an electronic health record. All members of the health care team should use the same hand-off process for each patient to help standardize care and promote safer patient transfer between health care providers.
References 1.
2.
3.
4. 5.
6.
7.
8.
9.
10.
Vidyarthi A, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257-266. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. http:// hcupnet.ahrq.gov. Accessed August 6, 2010. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. Nolan TW. System changes to improve patient safety. BMJ. 2000;320(7237):771-773. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physicianto-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. Safe Handover: Safe Patients. London, England: British Medical Association; August 2004. http://www .bma.org.uk/images/safehandover_tcm41-20983.pdf. Accessed August 6, 2010. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/PatientSafety/National PatientSafetyGoals. Accessed August 6, 2010. Ambler SW. Communication on agile software projects. http://www.agilemodeling.com/essays/communication. htm. Accessed August 6, 2010. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351(18):1838-1848. Perioperative Patient “Hand-Off” Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources/ToolKits/ PatientHandOffToolKit. Accessed August 6, 2010.