Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Arora, Vineet M.; Johnson, Julie K.; Lovinger, David M.; Humphrey, Holly J.; Meltzer, David O.

doi:10.1136/qshc.2005.015107

Cited by 509 publications

(401 citation statements)

References 27 publications

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“…These problems have been identified in interteam handoffs as well. 6,7 Even in optimized interteam handoffs, receivers fail to identify the most important piece of information about 60% of the patients, 8 and our results mirror this finding.…”

Section: Discussionsupporting

confidence: 66%

Intrateam coverage is common, intrateam handoffs are not

Martin

Frank

Fletcher

2014

Journal of Hospital Medicine

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Section: Discussionsupporting

confidence: 66%

Intrateam coverage is common, intrateam handoffs are not

Martin

Frank

Fletcher

2014

Journal of Hospital Medicine

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“…1 Handoffs have been recognized as a significant source of patient harm. The Joint Commission found that communication failures were the root cause of up to 60 % of adverse events, 2 and it is likely that handoffs represent vulnerable times for communication failures. Other studies have demonstrated a link between problematic handoffs with patient safety events 3 and increases in healthcare utilization.…”

Section: Resultsmentioning

confidence: 99%

Effect of a Systems Intervention on the Quality and Safety of Patient Handoffs in an Internal Medicine Residency Program

et al. 2013

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BACKGROUND: Poor quality handoffs have been identified as a major patient safety issue. In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content. OBJECTIVE: Determine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs. DESIGN: Before-after trial. PARTICIPANTS: Thirty-nine interns providing nighttime coverage over 132 intern shifts, representing ∼9,200 handoffs. INTERVENTIONS: Two interventions were implemented serially-an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff. MEASUREMENTS: Overall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators. RESULTS: In adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p<0.001) post intervention. Verbal handoff quality (4/ 10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p=0.001) and a non-significant reduction in near misses (p=0.056), but no significant difference in adverse events (p=0.41) post intervention.

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“…1,2 These errors can result in adverse events, longer hospital-stays, and increased use of medical resources. [3][4][5][6][7] In 2011, the Accreditation Council of Graduate Medical Education (ACGME) required that all residency programs implement a structured handoff protocol and develop a plan to monitor handoff quality. 8,9 More recently, the Association of American Medical Colleges (AAMC) identified handoffs as a Core Entrustable Professional Activities for Entering Residency (CEPAER) that should be assessed in graduating medical students.…”

Section: Introductionmentioning

confidence: 99%

The Modified, Multi-patient Observed Simulated Handoff Experience (M-OSHE): Assessment and Feedback for Entering Residents on Handoff Performance

et al. 2016

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BACKGROUND: Despite the identification of transfer of patient responsibility as a Core Entrustable Professional Activity for Entering Residency, rigorous methods to evaluate incoming residents' ability to give a verbal handoff of multiple patients are lacking. AIM: Our purpose was to implement a multi-patient, simulation-based curriculum to assess verbal handoff performance. SETTING: Graduate Medical Education (GME) orientation at an urban, academic medical center. PARTICIPANTS: Eighty-four incoming residents from four residency programs participated in the study. PROGRAM DESCRIPTION: The curriculum featured an online training module and a multi-patient observed simulated handoff experience (M-OSHE). Participants verbally Bhanded off^three mock patients of varying acuity and were evaluated by a trained Breceiver^using an expertinformed, five-item checklist. PROGRAM EVALUATION: Prior handoff experience in medical school was associated with higher checklist scores (23 % none vs. 33 % either third OR fourth year vs. 58 % third AND fourth year, p = 0.021). Prior training was associated with prioritization of patients based on acuity (12 % no training vs. 38 % prior training, p = 0.014). All participants agreed that the M-OSHE realistically portrayed a clinical setting. CONCLUSIONS: The M-OSHE is a promising strategy for teaching and evaluating entering residents' ability to give verbal handoffs of multiple patients. Prior training and more handoff experience was associated with higher performance, which suggests that additional handoff training in medical school may be of benefit.KEY WORDS: medical education; medical student and residency education; communication skills.

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Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Cited by 509 publications

References 27 publications

Intrateam coverage is common, intrateam handoffs are not

Intrateam coverage is common, intrateam handoffs are not

Effect of a Systems Intervention on the Quality and Safety of Patient Handoffs in an Internal Medicine Residency Program

The Modified, Multi-patient Observed Simulated Handoff Experience (M-OSHE): Assessment and Feedback for Entering Residents on Handoff Performance

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