Inadequate Handoff Communication

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

Omission of nursing care, such as failure to reposition patients, missing medications, and not responding to call lights, is usually unrecognized yet poses a threat to patient safety. Missed nursing care refers to any aspect of required patient care that is omitted or significantly delayed (Dabney & Kalisch, 2015). The more patients a nurse is providing care for correlates with more missed nursing care. This could result in failure to rescue, inadequate nutritional intake, and decreased mobility. Additionally, more missed care was reported by patients who also reported experiencing skin breakdown, medication errors, new infections, and other adverse events during hospitalization (Dabney & Kalisch, 2015). Patients are more likely to receive the wrong medication or medication too late with lower nurse staffing levels (MN

Given the complexity of healthcare system today, effective and efficient collaboration and communication among team members is critical to ensure patient safety. Daniel & Rosentein (2008) reported that during a typical patient’s hospital stay, a patient may interact with 50 different employees that may include doctors, nurses, laboratory technicians, etc. They also reported that when healthcare professional are not communicating and collaborating effectively, patient safety is at risk for several reasons: break in communication flow, misinterpretation of information, incorrect telephone orders and overlooked orders.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

The significance of the study is to discuss and clarify why bedside reporting is the best method of patient handoff. The benefits associated with this kind of bedside reporting and if implemented, how it will be of help to

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

This article was selected as it explained and discussed the probable standardized procedure that health care organizations may have to follow for improvements in patient safety. This article explains how the inter-personal and professional relationship of different health care providers need to be maintained for better health care as explained in one of the chapters of health care management.

The National Patient Safety Goal 13 was to encourage patients to actively involve in their own care as a patient safety strategy. As per the Joint Commission (2007), the teach-back method is the preferred method to address that goal. According to Fenwick ( n.d.), “Teach-back can help providers communicate with people with low health literacy, but it can also help with communicating overall—even with people with proficient health literacy”. Both the National Quality Forum and The Joint Commission endorse the teach-back method for use in teaching and proper administration of discharge instructions for both the patients and caregivers (Fenwick, n.d.). The American Medical Association also provides the tool kit to educate health care professionals in the use of the teach-back method (Fenwick, n.d.).

Currently, at Rutland Regional Medical Center (RRMC) there is no structured process for case management to provide handoff to the primary care offices when patients are discharged from the hospital. The transition of care from hospital to home is a critical time, during which the risk of adverse event occurrence is high. According to Shivji, Ramoutar, Bailey, & Hunter (2015), 19%-23% of patients experience an adverse event following discharge to home. Elderly patients are at greater risk due to functional and cognitive limitations; this is compounded by the presence of co-morbidities and multiple providers (Nelson, & Carrington, 2011). According to the Rutland County Health Assessment (2012-2015), by 2017 it is estimated that the elderly (age > 65) will comprise approximately 21.1% of the county’s population. Clear, concise, and timely communication with cooperative care providers at discharge is critical for the elderly population (Morris & Hoke, 2015). Furthermore, according to Lattimer (2011), the lack of cooperation between providers at discharge can endanger patients ' lives and waste fiscal and human resources. The purpose of this paper is to examine the problem of handoff communication to primary care offices and to plan a recommendation for change to provide a consistent and structured process; thereby ensuring the safety of the community during transitions of care.

The electronic handoff tool used in this study, eSignout, features automated communication and responsibility transfer with no mandatory verbal communication. The quality of communication and incidence of adverse or near-miss events were evaluated before and after the intervention. The results indicated similar quality of communication and adverse or near-miss events before and after intervention. However, it was reported that the intervention improved the quality of verbal communication when it occurred. In addition, participants perceived the eSignout as more efficient and preferred eSignout over verbal handoffs. An earlier study done by Li et al. cited below showed limited improvement of handoff quality when computerized physician handoff tools were used. Therefore, future studies are needed to explore the potential benefit of replacing face to face handoffs with other forms of handoffs, such as electronic or tele-communicative handoffs.

One of the most important trends in healthcare is patient safety. A patient’s safety assists in their healing, and also reflects negatively or positively on the hospital. With associations such as The Joint Commission (JCAHO), The Centers for Medicare/Medicaid, and HealthGrades keeping a watch on everything hospitals do and how they are reimbursed, patient safety has become a top priority. One practice that hospitals have begun to implement is bedside reporting.

Some gaps that have been identified in the transition of care include lack of formal handoff training, undocumented care, and communication errors. According to Malekzadeh et al., (2013) shift handoffs are not formally taught to student nurses as part of their education, instead these skills are learned on the job. Therefore, deficiency in training can impact the communication and content delivered by the healthcare team resulting in the loss of information. At the same time, another gap identified in handoff reporting is

2012 Joint Commission Patient Safety Goals. (n.d.). Retrieved January 2014, from Captain James A. Lovell Federal Health Care Center: www.lovell.fhcc.va.gov/about/2012PatientSafetyGoals.pdf

In today’s health care system, “quality” and “safety” are one in the same when it comes to patient care. As Florence Nightingale described our profession long ago, it takes work and vigilance to ensure we are doing the best we can to care for our patients. (Mitchell, 2008)