Lost in the Shuffle
Looking ahead to shorter resident hours causing more frequent patient handoffs, hospitals are working to ensure vital information is communicated to the next shift.
Improving patient safety is a primary goal of rules limiting the work hours of medical residents. Yet one result of shorter shifts is the need to hand over the care of patients to other doctors more often—frequently without fully transferring information. According to research by Vineet Arora, a physician and associate professor at the Pritzker School of Medicine of the University of Chicago, the limits on resident hours that the Accreditation Council for Graduate Medical Education imposed in 2003 have meant that during a typical five-day hospitalization, a patient will be passed from one physician to another an average of 15 times. The July arrival of tighter restrictions on residents’ workloads will lead to still more handoffs.
Handoffs can be fraught with miscommunication and the inadvertent omission of important information, such as the rationale for a particular medication. One study by Arora and her colleagues found that important clinical data wasn’t accurately communicated between outgoing and incoming interns 60% of the time. And a study published in the Archives of Internal Medicine in 2007 found that teamwork factors, notably lack of supervision and handoff problems, accounted for 70% of malpractice cases involving trainee errors.
To combat such problems, teaching hospitals have adopted protocols that include both paper and electronic forms for recording patients’ medical histories and treatments. But according to Arora, much depends on time-pressured oral instructions. “During a handoff from one trainee to another, the focus is really on what needs to be done, not the complete story of why the patient is there,” says Arora. “There isn’t time for more than a quick summary.”
The new ACGME rules call for hospitals to review handoff procedures, look for ways to minimize transfers and ensure that residents are competent in communicating with other members of a patient care team. Meanwhile, Arora says, physicians could learn much from nurses, for whom patient handoffs have long been a priority. “In nursing there’s a dedicated time, a dedicated room and a culture that has developed around handoffs,” Arora says. “In contrast, physician sign-offs tend to happen at the last minute and on the fly, often in a noisy environment. That needs to change.”