Quality patient care in the hospital setting requires a team of health care providers, working together, to effectively diagnose and treat patients. Consider the team required to treat a surgical patient-care providers will include the surgeon, surgical assistants, anesthesiologist, nurses, and potentially many others if any problems arise. Patients are often “handed-off” from one provider to another, either due to a shift change or because the patient’s needs require care from a different type of provider. During the hand-off process, providers must communicate all of the patient-specific information needed to ensure the continuity and safety of the patient’s care. If one link in the chain fails to properly communicate important data, each subsequent provider will not have that information and the patient’s safety will be at risk.
Communication errors in the health care setting can be deadly. In fact, one study estimated that communication failures in U.S. hospitals and medical practices were responsible for at least 1,744 deaths in 2016 alone. Another study found that communication breaks down more often when two or more disciplines are involved, and that there’s a two times greater likelihood that a communication failure will result between providers from different disciplines (such as between a surgeon and an infectious disease specialist). Surgery patients are particularly at risk from being harmed by these communication errors, as one study found that 30% of communications about surgical procedures included a failure.
The Joint Commission (TJC), an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States, recently issued a Sentinel Event Alert and accompanying infographic focused on inadequate hand-off communication. In it, TJC acknowledges that failed hand-offs are a longstanding, common problem in healthcare, and reports that inadequate hand-off communication has caused wrong-site surgery, delays in treatment, falls, and medication errors.The publication goes on to explain that insufficient or misleading information, absence of safety culture, ineffective communication methods, lack of time, poor timing between sender and receiver, interruptions or distractions, lack of standardized procedures and insufficient staffing are all contributing factors hand-off communication breakdowns.
Each member of a patient’s healthcare team has a duty to not only provide quality care, but to ensure proper hand-off to the next provider. Because proper communication can literally make the difference between life and death, health care providers must take proper hand-off procedures seriously.
Sources:
CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).
Hu, Y. Y., Arriaga, A. F., Peyre, S. E., Corso, K. A., Roth, E. M., & Greenberg, C. C. (2012). Deconstructing intraoperative communication failures. Journal of Surgical Research, 177(1), 37-42.
https://insights.ovid.com/pubmed?pmid=22591922
Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, G. R., Reznick, R., … & Grober, E. (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care, 13(5), 330-334.
The Joint Commission. Sentinel Event Alert. 2017 Sep 12; (58):1-6.