Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff

Kitch, Barrett T.; Cooper, Jeffrey B.; Zapol, Warren M.; Hutter, Matthew M.; Marder, Jessica E.; Karson, Andrew S.; Campbell, Eric G.

doi:10.1016/s1553-7250(08)34071-9

Cited by 190 publications

(158 citation statements)

References 32 publications

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“…Families reported miscommunication with and between staff most frequently, whereas staff rarely reported such events. Patient safety events frequently entail miscommunication, 9 to which families may be particularly attuned. The implementation of this family-based patient safety reporting system provided new opportunities to learn about and improve the safety of health care provision without an additional reporting burden for health care providers.…”

Section: Discussionmentioning

confidence: 99%

Identification by families of pediatric adverse events and near misses overlooked by health care providers

Daniels

Hunc

Cochrane

et al. 2011

CMAJ

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Section: Discussionmentioning

confidence: 99%

Identification by families of pediatric adverse events and near misses overlooked by health care providers

Daniels

Hunc

Cochrane

et al. 2011

CMAJ

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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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“…Handoffs also represent a transfer of professional accountability (2). Handoffs between physicians-in-training (3)(4)(5)(6), between nurses (7)(8)(9), and between ancillary staff such as respiratory therapists (7) are well-described in the literature. In contrast, transitions of care at the attending physician level have been less well studied (10)(11)(12)(13).…”

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confidence: 99%

Are Attendings Different?. Intensivists Explain Their Handoff Ideals, Perceptions, and Practices

et al. 2014

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Purpose: What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care.Methods: Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012. Measurements and Main Results:Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs.Conclusions: A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.

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Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff

Cited by 190 publications

References 32 publications

Identification by families of pediatric adverse events and near misses overlooked by health care providers

Identification by families of pediatric adverse events and near misses overlooked by health care providers

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

Are Attendings Different?. Intensivists Explain Their Handoff Ideals, Perceptions, and Practices

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