Both as a former hospital administrator and now as a long-time medical malpractice lawyer, I’m interested in learning why common healthcare errors are so common.
Healthcare accrediting agencies study these trends, too. The Joint Commission, the nation’s oldest accrediting organization, highlights some recurring medical hospital, medical, and nursing errors in National Patient Safety Goals.
One of my favorite National Patient Safety Goals was announced in 2010, and it deals with hand-off communications.
In any organization—and hospitals are no different—errors tend to creep in at transition points.
Transition points come in a variety of shapes and sizes.
There’s a transition point when information is supposed to be communicated from one department to another—for example, an order for a CT scan. That order goes from the physician to the nurse to the radiology department to the radiology tech to the radiologist, then into report format that should be communicated back to a nurse or the ordering physician. There are lots of opportunities for someone to drop the ball.
Another transition point comes at shift change. Hospitalist physicians typically have set hours and when they leave for the day, it’s up to a different hospitalist to take over care. Specialty or consulting physicians are often on-call for several days at a time and then turn patient care over to someone else from their practice group. Day shift nurses turn over bedside care to night shift nurses.
The Joint Commission mandated that hospitals and healthcare organizations hospitals have a process for hand-off communication that provides for the opportunity for discussion between the giver and receiver of patient information.
Professional organizations recommend standardized tools to help both the giver and recipient of handoff communications remember the key elements. One of the best-known tools is abbreviated SBAR, which is short for situation, background, assessment, and recommendation. If you think about it, if that level of detail is communicated by outgoing healthcare providers to incoming healthcare providers for each patient, it is unlikely that much would go through the cracks.
Even better, I’m a big fan of having handoff communications being done in patient rooms at the bedside. This allows the patient to participate in the conversation to make sure that the correct information is being conveyed and that nothing is being left out.
Unfortunately, nurses and physicians are often short staffed and overworked, meaning that time is a premium commodity. One of the first things that seems to be sacrificed in these time-crunch situations is a detailed handoff communication. When this happens, it can needlessly endanger patient safety by:
• Delaying implementation of physician orders for new medications, radiology studies, or lab work.
• Preventing nurses from immediately recognizing important changes in clinical condition.
If you’ve been seriously injured in Texas because of poor healthcare teamwork, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.
