Ineffective Handoff Report

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

“Errors in communication give rise to substantial clinical morbidity and mortality (Riesenberg, Leitzsch, & Cunningham, 2010).” As a result, the Joint Commission has identified effective communication as one of its National Patient Safety Goals (Dunsford, 2009).

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

Giving and receiving an incomplete or inadequate patient hand-off could mean the difference between life or death. In 2006, The Joint Commission addressed hand-off communication as a National Patient Safety Goal, and in 2010, the objective became a standard. However, evidence still shows there are gaps and that “substandard or variable hand-offs have contributed to errors, care omissions, treatment delays, inefficiencies from repeated work, inappropriate treatment, adverse events with minor or major harm, increased length of stay, avoidable readmissions, and increased costs” (Halm, 2013). The Joint Commission reported in 2017 that “ineffective hand-off communication was the cause of the majority of medical errors, including sentinel events” ("Inadequate Handoff Communication," 2017). The hospital I selected for my clinic hours uses a communication form that has not been updated in several years. These are the reasons why I chose to update and improve the current hand-off form for my sustainable product to promote better communication and increase patient safety. Furthermore, research proves that “successful hand-off improvement programs have the potential to substantially improve patient safety” ("Inadequate Handoff Communication," 2017).

A significant amount of communication is done between nurses at handoff report, and the patient’s safety can also be compromised at this time (Sand-Jecklin & Sherman, 2014). In a study conducted regarding near miss incidents, nurses reported that handoff report is a contributing factor (Sand-Jecklin & Sherman, 2014). Communication errors are the leading cause of patient harm and are the root cause of 65% of sentinel events (Tobiano, Chaboyer, & Mcmurray, 2013). If the bedside report is

In the article, "Improving Patient Safety by Standardizing Handoff Communications" (Danis, 2007), the purpose of the study was to implement a standardized approach to handoff communication and to improve compliance in using a handoff communication form. The study was based on the lack of standardized communication as the root cause of issues surrounding how patients receive care and safety and addressed the JACHO 2006 National Patient Safety Goals requiring a standardized approach in handoff communications. The study found that implementing a handoff communication form increased communications about patients between staff of each department. It concluded that staffs were more aware of communication gaps and the difficulties in communicating in the complex health care environment. This study is important for bringing more awareness and solutions to the problem of interdepartmental communications to ensure that patients will continue to

Nursing handoffs is a type of report between two clinicians that are responsible for patients care and is an important part of transferring patient information (what, how, who and where) from one healthcare provider to another in clinical practice (Smith and Schub, 2014). Ineffective, inconsistent and incongruent communication during these handoffs continues to be a problem and a threat to patient safety. Effective handoffs are instrumental in providing for the successful quality of care that the patient is to receive (Abraham, Kannampallil & Patel, 2013). Medical errors, treatment delays, inappropriate treatment and/or care omissions can happen as a result of miscommunication during handoffs which could potentially lead to patient harm, longer stays, readmissions and/or increased costs.

‘Clear and complete communication between health care providers is a prerequisite for safe patient management. Which is a major priority of the Joint Commission's 2008 National Patient Safety Goals and long-term care (LCT). (Commission, 2008)

It has been proven that bedside handover with ISBAR has provided a safety transition and met patient’s satisfaction that gives more opportunity to clarify information (ACSQHC 2012). Although, bedside handover with ISBAR is strictly implemented, there are difficulties in the application due to ‘changes in complex social practices’ of nurses that somehow limits its uptake (ACSQHC 2012, cited in Jeffcott, Evans & Cameron 2009). This literature review sought to study the rationale as to the effectiveness of bedside handover with ISBAR framework in clinical settings; and to identify the common barriers to effective communication in bedside handover.

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.

It has been reported by various studies that most patient care errors occur during the handoff due to miscommunication between the caregivers and their reports regarding inaccurate information about the patient’s care, treatment and current condition.

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.

With the evolution of healthcare, patient handovers have become not only a concern in Ontario, but an international concern. The handover (or handoff), also known as a critical transfer point, is the communication between units and healthcare teams that involves the transition of patient information. During a period of care, a patient can potentially be treated by multiple healthcare members in various clinical settings across the continuum of care. The handoff can occur between specialized outpatient, emergency, surgical, and intensive care units and include encounters with numerous staff members at each interval. Some nursing units transfer or discharge their patients at a rate of 40-70% everyday (Friesen, White & Byers, 2009). Consequently,

A weakness in communication between interdisciplinary team members can impact patient safety and health . A recent study revealed that out of all the claims analyzed , 57 percent of malpractice cases reflected miscommunication between two or more healthcare providers (Riah, 2015). In fact, the same communication failures directly linked to 1,744 deaths over the past five years (Budryk, 2016). During my clinical placement this semester I have witnessed the overwhelming number of health care team members that are involved in each patient’s care. I also take part in morning nursing rounds where all nurses are updated on every patient’s status. Transmission of permanent patient information is also relayed to all members of the health team via the patient chart .Here , interdisciplinary notes all come together to form updated health information on patients. However, although I have read interdisciplinary notes from all team members , I rarely have had the opportunity to personally communicate with members other than doctors and nurses. Personal communication allows for a team member to pass on relevant information in a timely manner without the possibility or misinterpretations. When communication is strictly done non-verbally, it is impossible to ask any questions.. This is why communication between professionals in health care is essential for patient safety and improved quality of care (Koivunen, Niemi., & Hupli,2015). There are 3 main factors that cause miscommunication

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to