Study after study has shown that one of the biggest contributors to medical errors and negligence is poor communication among healthcare providers. In a race, one runner does his or her part and then passes the baton to a team member for the next segment of the race. In the health care setting, the baton is frequently not passed, it is dropped.
In an effort to stop this breakdown in communication that endangers patient safety, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to train nurses and physicians on ‘handoff communications.’
Handoff communications occur when one healthcare provider passes specific patient information to another provider to ensure move forward the patient’s care. This is called continuity of care because, when it works, it is a continuous process.
For example, a doctor makes an order for some lab work in a handoff communication to the nurse, the nurse executes the order in a handoff communication to the lab, then the nurse or lab communicates the results back to the doctor in a handoff communication, and a doctor may make new orders based on the lab results in a handoff communication to the nurse. The process goes on and on and promotes continuity of care.
In order to maintain accreditation, JCAHO requires hospitals to implement standardized procedures for handoff communications.
But what happens when there is a break in the handoff communication process? As a Texas medical malpractice attorney, I see this happen a lot when it comes to physician orders for radiology procedures (CT, MRI, etc.) or labs. When doctors and nurses ignore their duty to make handoff communications, patients are needlessly endangered.
I can give some real-world examples of how this happens.
This year I have worked on two cases involving brain injuries where there were the physicians ordered stat head CT (cat scan) images. Most lay people and patients realize that a ‘stat’ order means ‘now’ or ‘as soon as possible.’ But when doctors or nurses drop the baton by not having a handoff communication they end up pointing the finger at each other rather than getting patients the care they need.
In both of the cases I mentioned it took over four hours for the stat CT images to be interpreted. In both cases there was no handoff communication. In one case, the hospital blamed the doctor and said it was up to the ordering physician to check back regularly to make sure the CT was complete.
In the other case, the doctor said the nurses were obligated to report back to him once the CT was done. Instead of getting the job done, the nurses and doctors were pointing fingers at each other.
Tragically, in both cases, there was a needless long delay in implementing badly-needed treatment, causing avoidable permanent injuries.
Hospitals need to take seriously their effort to require doctors and nurses to make proper handoff communications, in order to keep their patients safe. Handoff communications provide the safety net to make sure that no part of patient care falls through the cracks.
I recommend that patients and their families take an active role in healthcare through asking questions and following up. When a CT is ordered, for example, it is appropriate for the patient or family members to ask how long it will take to be interpreted, and then to follow up during that time interval.
If you or a loved one has been injured by poor healthcare, call the Texas medical malpractice lawyers at Painter Law Firm, at 281-580-8800, for a complimentary evaluation of your potential case.
