Transfer of hospitalized patient from one resident to another can lead to harm

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Hospital residents report patient-handoff problems common

A significant percentage of resident physicians report that patient handoffs – transfer of responsibility for a hospitalized patient from one resident to another – contributed to incidents in which harm was done to patients.  The study, published in the October 2008 Joint Commission Journal on Quality and Patient Safety, identifies situations in which problematic handoffs are more likely to occur and factors that may interfere with the smooth transfer of crucial information.

“Our findings suggest that patient harm from problematic handoffs is common,” says Barry Kitch, MD, MPH, of the Massachusetts General Hosptal (MGH) Institute for Health Policy and Harvard Medical School (HMS), lead author of  the study.  “In fact, problematic handoffs may be as significant a source of serious patient harm as are medication-related events.”

Several previous studies have shown that handoffs can contribute to adverse events – preventable injuries that do not result from patients’ underlying medical condition – and concerns about potential handoff-related hazards have increased since restrictions on the hours that residents can work require even more frequent handoffs.  The current study, conducted late in 2006, was designed to analyze residents’ experience with handoffs and their perception of how often handoffs were a factor in adverse events.

Surveys were distributed to 238 MGH medical or surgical residents, asking about their experiences with handoffs during their most recent inpatient rotations.  Questions included how much time they spent preparing for and taking part in handoffs; the types of information involved in handoffs; how often important information was missing, complete or inaccurate; factors associated with problematic handoffs; and how many patients experienced harm attributed to such handoffs.

Completed surveys were returned by 161 residents, a response rate of almost 68 percent; and more than half the respondents reported at least one incident of handoff-related patient harm during their monthlong inpatient rotations.  Major patient harm – including significant worsening of clinical status, prolonged hospitalization, disability or death – resulting from handoffs was reported by about 12 percent of residents, a total of 29 major events, although the same event could have been reported more than once.  To maintain survey anonymity, respondents were not asked for detailed descriptions of the events.

While 94 percent of handoffs were conducted face-to-face, more than half the respondents reported they were rarely done in a quiet, private setting, and over a third reported frequent interruptions.  Half the residents also reported that problematic handoffs reduced their ability to provide complete and accurate information to patients, family members and other health care professionals; and one third rated the overall quality of handoffs during the rotation as fair or poor.

 “The study’s findings that handoffs associated with  patients’ admission to the hospital were more likely to be problematic suggest specific areas to address,” says Kitch, an instructor in Medicine at HMS.  “The survey also confirms observations that handoffs are not routinely conducted in ways that minimize problems, such as in quiet, interruption-free settings.  Further study of the causes and nature of handoff-associated events will help guide future efforts.”

In recognition of the growing national concern about the potential of problematic handoffs to harm patients, the MGH partially funded the study and now is using the results to focus and drive improvements in the handoff process.  Efforts to improve the safety and effectiveness of handoffs – under the auspices of the hospital’s Center for Quality and Safety, led by Gregg Meyer, MD –  includes enhancement of computerized handoff-support tools, programs to teach and support best practices, and more specific, hospitalwide process improvement projects, notes study co-author Andrew Karson, MD, MPH, who is overseeing the handoff-improvement projects.

The senior author of the current study is Eric Campbell, PhD, of the MGH Institute for Health Policy and additional co-authors are Jeffrey Cooper, PhD, MGH Biomedical Engineering; Warren Zapol, MD, MGH Anesthesia; Matthew Hutter, MD, MPH, MGH Surgery; and Jessica Marder, Institute for Health Policy.  The study was also supported by grants from the National Heart, Lung and Blood Institute; and the Agency for Healthcare Research and Quality.