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Doc-to-Doc 'Hand-Offs' Impact Patient Safety

Hospitals must improve communication during shift changes, study finds

FRIDAY, Dec. 16, 2005 (HealthDay News) -- As many hospitalized patients can attest, doctors will often turn their care over to another physician during the course of their stay.

But a new study finds that doctor-to-doctor communication during these hand-offs is often inadequate, raising risks for treatment errors.

Of all the errors in treatment of patients in hospitals, "it's been estimated that as many as 75 percent involve some breakdown in communication. It's a big problem," said study co-author Richard M. Frankel, of the Indiana University School of Medicine, in Indianapolis. His report appears in the December issue of Academic Medicine.

During each hand-off, doctors are supposed to share information about the patient's history, condition and medications. Since this type of transfer can occur several times during a 24-hour hospital stay, inconsistencies in the quality of these hand-offs increases the odds for omissions or mistakes, Frankel said.

He compared the situation to another high-pressure vocation, air traffic control, where the smooth transfer of information is crucial to ensuring safety. But Frankel said air traffic controllers have developed a systematic, uniform regimen to insure that data is accurately passed along as shifts change throughout the day.

That isn't the case in his own hospital system, Frankel said. His team found that the four different teaching hospitals included in the Indiana University School of Medicine system use three different computer systems, and "hand-off procedures" are different at each hospital. At some centers these procedures are computer-assisted, while others rely on handwritten forms.

"In this complicated area of hand-offs, there was great variety in hand-off protocol, and no standardization," he said.

Reviewing procedures at their own hospital system and looking over the available literature on systems elsewhere, Frankel's team identified the most common reasons for poor information transferal. These included noisy, distracting physical settings that impede conversation; the hierarchal nature of medicine (which can discourage open discussion between health professionals); language barriers among doctors; lack of face-to-face communication; and time pressures.

Many doctors may simply not be aware that there is a problem, Frankel said.

"Modern medicine has evolved fairly quickly, and in a technological age, people have just assumed that they were getting it right," he said.

As a result, he said, medical schools have paid little attention to the importance of teaching doctors about hand-offs. In a 2004 survey Frankel conducted among 125 medical schools, only 8 percent taught students how to hand off patients. The large majority of students are taught by interns or residents, Frankel found.

The researchers are now recommending that medical schools instruct interns about hand-off procedures, and that a hand-off "protocol" be developed for doctors working at a particular center.

Particularly important, the authors write, "is to emphasize an attitudinal shift from the concept of 'sign-out' or 'babysitting overnight' to an assumption of primary-care responsibilities for that patient."

They also recommend the use of computers in keeping track of patient information and conducting hand-offs in face-to-face encounters, to ensure the correct transfer of data.

"This is a really important area that we haven't paid sufficient attention to," Frankel said. "We present it not to punish people, but in the spirit that 'All boats float when the quality improves.'"

Matthew Grissinger, a medical safety analyst with the nonprofit Institute for Safe Medication Practices, said the study recommendations made are similar to National Patient Safety Goals announced last year by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Those guidelines mandated improvements in hospital care, including the requirement that detailed information on patients' medications accompany them whenever they are transferred to another part of a hospital.

Grissinger said hospitals, not individual doctors, must take the lead.

"This study does a great job in identifying the problem, but it is more important that an organization addresses this rather than an individual doctor," he said.

More information

For more on recommended hand-off procedures, head to the Joint Commission on Accreditation of Healthcare Organizations.

SOURCES: Richard M. Frankel, Ph.D., professor, medicine, Indiana University School of Medicine, Indianapolis; Matthew Grissinger, medical safety analyst, Institute for Safe Medication Practices, Huntingdon Valley, Pa.; December 2005 Academic Medicine
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