Q&A: How to improve patient handoffs

Briefings on Accreditation and Quality, November 1, 2017

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Patient handoffs continue to be a major concern for hospitals. In September, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and its effect on patient care. Handoffs (also known as transitioning) are the passing of patients between caregivers, plus the information that caregivers exchange during the process. The latter represents a major point of failure for healthcare; each handoff runs the risk of key treatment information being garbled, forgotten, or not passed on.

These transfers can be as dramatic as air-lifting a patient to a remote specialty hospital and telling the EMTs that the patient thinks he can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine. In both cases, not passing on this information can potentially harm the patient.

“Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. “When handoff communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete, or nonexistent documentation, to name just a few.”

The following is an edited Q&A with Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, on improving patient handoffs.

Q:      How much of an impact do patient handoffs have on care quality? What can happen if they go wrong?
Patient handoffs have a profound effect on the quality of care and patient outcomes. The information provided during a handoff plays a key role in assuring that the care the patient needs is seamlessly provided. Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information. Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.

Q:     Is there a national, standardized handoff procedure in healthcare? In other words, is there a set of procedures all hospitals are meant to follow, or do they decide individually how their facility will conduct handoffs?  
There is not a current standardized handoff procedure that is used in healthcare. Each healthcare organization can establish its own procedures to meet the needs of their patients, providers, and patient care staff. That said, there are models, or formats, that are adapted by many hospitals to develop their procedures. For example, SBAR (Situation, Background, Assessment, and Recommendation) and “I-PASS” (Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver) are two such tools.

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