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Flubbed handoffs of patients between doctors leads to errors, MGH survey finds

E-mail | Print | Comments () Posted by Elizabeth Cooney September 23, 2008 03:23 PM

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Patients routinely have responsibility for their care passed from one physician to another as doctors' shifts end or as patients move from one department or hospital to another. When schedules of resident physicians were limited to 80 hours a week in 2003, the expected increase in handoffs -- already a cause for concern because of the chance for miscommunication -- attracted more attention.

A 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety. More than half of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs. About one in nine said the harm that resulted was significant.

"Problematic handoffs may be as significant a source of serious patient harm as are medication-related events," Dr. Barry T. Kitch of the MGH Institute for Health Policy said in a statement.

Problematic handoffs were defined as having inaccurate, incomplete, or missing information, the authors say. The survey took place before the hospital had begun using its formal electronic sign-out tool. Almost all the residents said the handoffs were face-to-face, almost half said they rarely occurred in a quiet setting, and more than a third said they were interrupted at least once.

If the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely, the residents said.

The authors recommend compiling better information for handoffs and conducting them in a quiet, uninterrupted setting that allows questions to be asked.

"We believe that a useful step ... would be to change the culture from one of viewing handoff-related harm as inevitable to one in which error minimization is seen as mandatory," the authors write.

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About white coat notes

White Coat Notes covers the latest from the health care industry, hospitals, doctors offices, labs, insurers, and the corridors of government. Chelsea Conaboy previously covered health care for The Philadelphia Inquirer. Write her at cconaboy@boston.com. Follow her on Twitter: @cconaboy.

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