The Joint Commission, a healthcare accrediting agency, describes hand-off communications as the transfer and acceptance of patient care between physicians, providers, or nurses.
Hand-off communications happen thousands of times every day. There should be a handoff communication every time a nurse changes shifts or a new attending or resident physician rotates onto a service.
As a former hospital administrator, I recall this topic coming up frequently. Registered nurses can be diligent about tending to a patient during the whole shift, only to drop the ball when care is transferred to a new nurse. The same challenges apply to physicians, physician assistants, and nurse practitioners.
Poor communication when care is transitioned from one physician, provider, or nurse to other health care personnel can happen when:
• Patient information isn’t complete
• Patient information isn’t timely
• Patient information is misinterpreted
• The necessary information isn’t communicated
The problem is so significant that over 15 years ago The Joint Commission announced a National Patient Safety Goal to highlight hand-off communications.
What should be in a hand-off communication?
Hand-off communications should include, at a minimum, the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these things. It’s not enough to document these findings in the patient’s medical record—that information sometimes is lost through the cracks or there’s a delay in reviewing it.
The key to a good hand-off communication is communication, meaning that information is actually conveyed by one person and received by another so it can be applied immediately in ongoing patient care.
The idea behind hand-off communications is that the new members of the medical and healthcare team should be empowered to hit the ground running to provide safe, quality patient care without any interruption.
Poor transitions in care have been linked to adverse events and bad outcomes, including wrong-site surgery, delay in treatment, falls, and medication errors. One study found that poor communication practices of medical and health professionals contributed to at least 30% of all medical malpractice claims.
One of the tenets of medical and nursing care is establishing each patient’s baseline and then looking for changes to the baseline through reassessments. When there’s poor communication between outgoing and incoming shifts, that baseline information may be lost.
This reminds me of a case that we handled involving a pediatric patient at a major children’s hospital in Texas. Let’s call her Lisa. This 10-year old girl’s parents brought her to the hospital because she had been having on-and-off headaches for a few weeks, which had suddenly worsened in intensity, accompanied by nausea and vomiting.
When Lisa got to the hospital, she was alert and oriented, and able to talk and move around. The physicians ordered CT and MRI scans of her head, which showed some abnormalities that were concerning for a brainstem mass. The neurosurgeon was consulted and felt it would be safe to take Lisa to surgery the next day, so long as she remained the same. In other words, it was important for everyone to know Lisa’s baseline.
On the shift change, the handoff communication was incomplete. After the shift change, the new nurses documented that Lisa was lethargic and difficult to arouse. Later, Lisa had such intense head pain that she was screaming. The nursing staff apparently thought that these new findings weren’t a significant change of Lisa’s baseline, even though she was on a neuro floor with orders for heightened neuro monitoring. Thus, no one immediately notified a physician.
By the time they got a doctor was summoned, in the middle of the night, Lisa had gone into respiratory arrest and was completely unresponsive. Her neurologic condition had unexpectedly crashed. Our experts believe that if there had been good communication between the outgoing and incoming medical and health team, then Lisa’s condition could’ve been emergently addressed by the neurosurgeon. Instead, she was left with a profound brain injury, in a permanently unresponsive state.
If you’ve been seriously injured because of poor hospital, medical, or nursing care in a Texas hospital, then contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.
