SESSION TITLE: Patient Safety Initiatives
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Wednesday, October 29, 2014 at 07:30 AM - 08:30 AM
PURPOSE: An estimated 200,000 to 400,000 deaths in the U.S. per year are attributed to preventable medical errors, making medical errors the third-leading cause of death. Breakdown in communication is an important source of medical errors. Handoff between healthcare providers is a well-recognized source of miscommunication and information loss. We studied provider agreement about important patient information and outstanding patient care tasks after handoff in a medical-surgical intensive care unit (ICU).
METHODS: We observed serial handoffs between medical providers (physicians and nurse practitioners) at shift change in a mixed medical-surgical ICU at a tertiary academic medical center. The outgoing and incoming providers (consultants, fellows, NPs) were asked to fill out a short survey about 3 patients directly after the handoff. The survey inquired about the patient’s reason for staying in the ICU, the most important information communicated at handoff, the pending tasks for the next shift, and the perceived quality of the handoff. Interruptions during the handoff process were recorded by the observer.
RESULTS: We observed a total of 42 patient handoff processes in a 2-week period. Providers agreed about the patient’s primary reason for staying in the ICU in 66.7% of patients (standard deviation (SD) 25.5%). The highest level of agreement was observed among fellows (mean 71.4%, SD 25.7%), compared to 66.7% among NPs (SD 26.2%), and 61.9% among consultants (SD 25.7%). 38.1% of providers (SD 28.1%) agreed about the most important information communicated during handoff. Consultants had the highest level of agreement (mean 45.2%, SD 31.0%), compared to NPs (mean 35.7%, SD 24.3%) and fellows (mean 33.3%, SD 29.2%). The outgoing and incoming team members agreed on only 37.4% of the tasks for each patient (SD 24.9%). Most team members were satisfied with the quality of the handoff (median 5, interquartile range 1, on a Likert scale from 1-7). 42.9% of the observed patient handoffs were interrupted. 64.3% of the interruptions could have been prevented, and 85.7% were partial interruptions involving only one team member.
CONCLUSIONS: We found significant disagreements between outgoing and incoming medical providers about the reasons for ICU admission, main problem, and outstanding tasks for each ICU patient after handoff.
CLINICAL IMPLICATIONS: Handoff between ICU providers represents an important source of miscommunication, which could lead to medical errors. Improving the handoff process may help prevent medical errors.
DISCLOSURE: The following authors have nothing to disclose: Andrea Braun, Sumedh Hoskote, Carlos Racedo Africano, John OHoro, Ronaldo Sevilla Berrios, Theodore Loftsgard, Kimberly Bryant, Vivek Iyer, Nathan Smischney
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