Improper patient handoffs cause thousands of deaths every year: Study

We all know the power of the spoken word. And now a study shows that words, or in this case a lack of them, can kill. According to the study, a lack of proper communication during shift changes is the most common reason for medical errors in healthcare centers. In fact, the Institute of Medicine estimates that the above mentioned errors account for approximately 98,000 deaths (that could have been prevented) every year.

Researchers at the Richard L. Roudebush VA Medical Center and the Regenstrief Institute published two studies online that provide rare insights into the end-of-shift exchanges currently in practice. Details of the study can be gathered from the BMJ Quality and Safety journal.

The researchers based their findings on audio and video recordings of actual handoffs. The recordings confirm that the lack of communication evident in the handoff procedures in other industries, like the aviation industry and nuclear power industry, exists in the healthcare industry, too.

The current study also focuses on the details of actual patient handoffs, and how the ability to rectify errors and ambiguities in dialogs during face to face interaction can be hugely beneficial in bringing down the error quotient.

While completing a computerized checklist at the end of a shift might be time-saving and more convenient for an outgoing physician, checklists don’t typically contain all the necessary information. Take, for example, a case where a patient refuses to walk because it’s painful or a patient has been asking for a loved one – this kind of info would never find its way onto a checklist. But this type of information could be crucial to an incoming physician.

The incoming physician needs to know which patients are the sickest. He or she will also benefit from knowing what problems the outgoing physician thinks could happen in the next eight to 12 hours. These are things that can easily happen in a face-to-face dialog, but are hard to convey via a static shift checklist. More importantly, asking questions clarifies any ambiguity and allows for improvisation.

According to Alicia A. Bergman, Ph.D., first author of one of the studies, ambiguity, inaccuracies or limited information may lead to improper medication, wrong doses, inaccurate treatments, missed opportunities and other medical errors. A face to face dialog allows for a certain amount of in-the-moment-improvisation that can enrich the level of care and give room for better prognosis.

The poor transfer of information during handoffs in healthcare centers is a long-standing problem. It has been identified as a safety goal target by the Joint Commission (the organization that accredits healthcare organizations and programs). But in spite of this, traditional medical education at the university levels and even basic hospital training do not put too much importance on patient handoffs.

According to Dr. Frankel, author of a 2005 Academic Medicine study which found that only about 10 percent of medical schools offer their students training in handoffs, the percentage has not risen much over the past 10 years since his report. This is indeed a cause for concern because, thanks to mandated reductions in resident work hours from 110 to 80 hours per week and the increased employment of hospitalists, handoffs within healthcare centers, as well as inter-hospital handoffs, are on the rise.

The authors conclude that in spite of a trend toward computerized checklists, face to face communication, including the opportunity to spontaneously ask and answer questions, will play an important role in improving the safety of patient handoffs. Not to say that computerized checklists are to be discarded. The ideal scenario would be where the custodians of health in the healthcare centers use both computerized checklists as well as face-to-face dialog in tandem during handoffs.