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What Gets Said Should Be What's Heard; What Gets Heard Should Be What's Meant

The poor exchange of information at change of shift is one of the most common causes of medical errors at hospitals across the country. These errors have been estimated by the Institute of Medicine to cause as many as 98,000 preventable deaths annually.

Two new studies from the Richard L. Roudebush Veterans Affairs Medical Center and the Regenstrief Institute published online in advance of print in BMJ Quality and Safety provide unique insights into end-of-shift handoffs. 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, plays an important role in improving the safety of patient handoffs. 

These findings, based on the review of actual handoffs that were audio and, in some cases, video recorded, confirm what has been found regarding communication in other industries such as aviation and nuclear power. Also new in these studies is the focus on the details of actual patient handoffs and the importance of being able to repair errors and ambiguities in conversations 'in the moment' during face to face interaction.

"While it's faster and easier for a physician to complete a computerized checklist at the end of a shift, checklists don't typically contain much psycho-social information—for example, the patient refuses to walk because it's painful or the patient has been asking for a loved one," says Richard M. Frankel, PhD, a VA and a Regenstrief Institute investigator and an Indiana University professor of medicine, and senior author of both the BMJ studies.

"But this is the type of information the incoming physician needs to know," Frankel says. "She or he also needs to know which patients are the sickest and what are the likeliest problems the outgoing staffer thinks the incoming colleague will encounter in the next eight to 12 hours. That's easy to talk about but hard to convey via a static shift checklist. And importantly, asking questions clarifies ambiguity and allows for improvisation." 

Ambiguity, inaccuracies, or limited information may lead to incorrect medications, wrong doses, inappropriate treatments, missed opportunities, and other medical errors. Improvisation enables the questions and answers to emerge in the moment and enhance care, according to Alicia A. Bergman, PhD, first author of one of the studies. She is a former Regenstrief Institute and VA health services research fellow in Indianapolis and is now with the VA Greater Los Angeles Healthcare System.

In spite of being specifically identified by the Joint Commission (the organization that accredits health care organizations and programs) as a safety goal target, patient handoffs are an area that is not typically included in medical education according to Frankel, who is also the author of a 2005 Academic Medicine study that found that only about 10% of medical schools offer their students training in handoffs, a percentage he says has not risen significantly over the past decade.

With mandated reductions in the number of intern and resident work hours from 110 to 80 hours per week and the increased employment of hospitalists, handoffs in hospitals, as well as between hospitals and nursing homes are increasing.

In addition to Frankel and Bergman, authors of "'Mr. Smith's been our problem child today…' Anticipatory Management Communication (AMC) in VA End of Shift Medicine and Nursing Handoffs" and "'Anybody on this list that you're more worried about?' Exploring the Functions of Questions During End of Shift Handoffs" are Mindy E. Flanagan, PhD, and Colleen M. O'Brien, JD, MPH, of the Roudebush VA Medical Center, Indiana University School of Medicine, and Fairbanks School of Public Health,  and Patricia R. Ebright, PhD, RN, of the Indiana University School of Nursing.

Source: Indiana University School of Medicine