How to improve care transition safety

CHICAGO—When Vineet Arora, MD, MAPP, took the podium at the 2014 Healthcare Leadership Forum, she began with a call to improve handoffs in healthcare. “Making transitions safer is a national patient safety goal,” said Arora, who is associate professor of medicine and director of the Graduate Medical Education Clinical Learning Environment Innovation at the University of Chicago Pritzker School of Medicine, citing the Joint Commission. “But really, it’s a requirement.”

Across the continuum of care there are opportunities to improve handoff communications and reduce the amount of transition-related errors. There are a number of different handoff scenarios on the inpatient side, from inpatient to outpatient, within outpatient, and from hospital to home care. The World Health Organization (WHO) as well as many other healthcare organizations such as the Society of Hospital Medicine, have launched safety initiatives and/or published information about the number of preventable medical errors that happen due to miscommunication during transition of care.

As a hospitalist, Arora spoke in-depth about intra-hospital handoffs. From the ED and admission to intra-hospital transfers and shift changes, there are multiple points where communications can break down and errors can occur. There are different considerations to be made in each scenario. For example, in a shift change, the sender may be returning during another shift to care for the same patient. During a service change, a whole new team may be taking over care for that patient.

“Service transfers occur when you are escalating or de-escalating care for a patient. This may mean they are going in or out of ICU, or going from surgery to post-surgical care, or being transferred to a specialty unit,” said Arora. “These handoffs are really a type of communication, whether written or verbal, and importantly, they are a transfer of professional responsibility.”

According to Arora, speakers systematically overestimate how well their messages are understood by listeners. Senders of communication assume that the receiver has all of the same knowledge that the speaker has.

Arora reviewed tests she conducted to assess the success of handoff communications in inpatient pediatrics. Incoming and outgoing pediatric interns were interviewed one hour after handoff. They were asked to identify the single most important thing about the transfer. They were incorrect 60 percent of the time.

Arora said that sometimes we communicate in vague language; we give data, but not information. Instructions to check CBC may induce the next shift to run the bloodwork, but they were not given any specific instructions about what to look for.

“This is the most common thing we see,” said Arora. “This is not specific. A more effective scenario would be: Check CBC and if X is low, then do this.”

In the testing, if/then items were remembered 69 percent of the time. To-do list items were remembered 65 percent of the time, and general information about the patient was remembered at a rate of 35 percent.  

Arora explained there is a tension between too much and too little information. More is not necessarily better. The average person can’t remember more than four or five things. Our ability to group information and numbers is a proven method for remembering more bits of information. This approach, called chunking, was used in remembering Social Security numbers and phone numbers (back when we had to actually memorize them).

Arora suggested handoffs can be organized the same way, with the sickest patients first, and then on down the line. There are other proven approaches to grouping data and remembering information, used by organizations such as NASA, railroad dispatch, the Navy and Starbucks of all places.

At Starbucks, staff are trained using the read-back approach. When customers order coffee, the first thing the barista does is read the order back to make sure they’ve understood correctly. If they make the coffee wrong, they’ll have to make another one. The same remedy unfortunately does not apply in healthcare.

Arora cited a read-back study conducted at Northwestern Memorial Hospital in Chicago. According to the study, there were 29 errors detected in requested read-back of 822 lab results. Read-back is cost effective, but there are other approaches that help reduce handoff errors including: standardization of the handoff, providing updates of the information, limiting interruptions and conducting a face-to-face verbal update as part of the handoff. Arora explained at her facility, they don’t encourage read-back for all the handoffs, but do it consistently for the sickest group of patients.

 “The verbal handoff is best understood as a dialogue,” says Arora. A dialogue fosters common ground and the person that needs to be most invested is the receiver. There are cues the sender can see to verify the receiver is getting the message such as eye contact, nodding and body language.

Distractions and interruptions often derail the transfer of important information during a handoff. Arora offered examples from her work. Distractions came mainly from phones or talking. She noted that most people in her study were doing passive listening and less than 10 percent of the groups studied used read-back.

Most interruptions came from side conversations. These conversations were either about personal or professional well-being (commiserating, comradery), or system-related venting. The handoff should not be the time for these types of conversations, according to Arora.

According to Arora, there are definite ways to improve handoff communications including:

• Focus on the sickest patients first
• Offer directions with rationale
• Encourage read-back
• Design schedules with overlap to define the time for handoffs and minimize handoff interruptions

Arora and her team conducted an audit of written signoffs at a facility and found that 1/3 of medication on signoffs were incorrect.

“We found that omissions of medication were common, but it is the commission that is more serious. Forgetting to include medication the patient is taking is a common omission, but leaving medications on the list when the patient has been taken off of them can endanger the life of the patient. The longer the patient stays, the higher the risk of error,” Arora explained.

There are opportunities to improve the written handoff with more efficient documentation. Oftentimes, according to Arora, there is a disturbing amount of copying and pasting on to the transfer document. This excess of information leads to an inability to identify what’s important, and worse, prior to the electronic medical record, the transfer document was the most up-to-date information in a patient’s chart.  

Using standard fields for diagnosis, treatment team and a to-do list, and including a place to log when the data was last refreshed helps to organize the written handoff.

“Current diagnosis fields that are right out front, and an ability to see when the information was last updated helps to maintain accuracy and prevent errors. For example, if a patient had a stroke on day four of their hospital stay, that information shouldn’t be buried in the notes,” Arora says.