Last month’s “Risk Management and Patient Safety News” column titled “Healthcare Communication Failure: 13 Ways to Improve Communication” emphasized that communication breakdowns are one of the root causes of preventable patient injury. It identified seven types of communication failures that result in patient injury and in malpractice claims. The first communication failure was incomplete handoff between providers regarding a patient’s condition.
This article will provide specific information about the importance of good handoff communication.
Handoffs occur any time there is a transfer of responsibility for a patient from one caregiver to another. Regulatory and accrediting bodies are well aware of the dangers of ineffective handoffs. The Joint Commission issued the following Sentinel Event Alert on Inadequate Handoff Communication:
“…. When a patient is handed off to another healthcare provider for continuing care, treatment, or services, the type of information the receiving provider needs may not be the information the sender provides. This misalignment is where the problem often occurs during handoff communication.” i
Also, a recent study stated that hospitals and doctors’ offices nationwide might have avoided nearly 2,000 patient deaths—and $1.7 billion in malpractice costs —if medical staff and patients communicated better. “Communication failures were a factor in 30 percent of the malpractice cases examined by CRICO Strategies, a research and analysis offshoot of the company that insures Harvard-affiliated hospitals. The cases— including 1,744 deaths—involve some horror stories that no family, and no medical professional, wants to experience. In one instance, a nurse failed to tell a surgeon that a patient experienced abdominal pain and a drop in the level of red blood cells after the operation —alarming signs of possible internal bleeding. The patient later died of a hemorrhage.” ii
Mnemonics and standardized handoffs can be helpful in these instances. As the case example shows, it is vital to patient safety to ensure clear communication amongst the treatment team. CAP recommends that physicians and other members of the treatment team memorialize conversations about a change in a patient (positive or negative) in the medical record. To aid in this patient safety effort, several mnemonic tools have been developed to assist members of a patient’s healthcare team in achieving systematic and standardized handoff communication. Three of the tools are listed below and include:
Document the FIVE-Ps (Patient, Plan, Purpose, Problems, and Precautions) iii
SBAR (Situation, Background, Assessment
and Recommendations iv
I PASS the BATON (I = Introduction, P = Patient, A = Assessment, S = Situation, S = Safety concerns, B = Background, A = Actions,
T = Timing, O = Ownership, N = Next) v
More importantly, and irrespective of which system you use, it is critical that you document your evaluation in your patient’s progress notes, or if a form, such as a discharge form, is filled out, it is memorialized in the patient’s records. Moreover, if you know handoff communication is a problem for you and for your patients, it is imperative to identify and correct systemic issues that prevent effective handoffs, be it turf wars, interruptions, and/or the unavailability of pertinent or pending test results and other data.
Remember—it is vital to patient safety to ensure that there is clear communication amongst the treatment team.
1. Do not assume that the primary care physician received pertinent records regarding the admission
2. Review all pertinent tests and results, and determine which specialists saw the patient, and what the follow-up plans are
3. Convey any lab or diagnostic results that were outstanding at discharge and clearly designate responsibility for following up on outstanding results
4. Ensure that it is hospital policy to forward discharge summaries to the PCP of record
5. Provide a thorough, timely discharge summary
i https://www.jointcommission.org/sentinel_event_alert_58_inadequate_hand…
ii https://www.statnews.com/2016/02/01/communication-failures-malpractice-…
iii ibid
iv http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx
v https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
Anne Marie Lyddy is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to alyddy@CAPphysicians.com