Patient Harm From Problem 'Handoffs' Is Common: Report

FRIDAY Sept. 26, 2008 -- The process of transferring the care of a hospitalized patient from one resident to another tends to cause some amount of harm to the patient, a new study suggests.

"Our findings suggest that patient harm from problematic handoffs is common. In fact, problematic handoffs may be as significant a source of serious patient harm as are medication-related events," lead study author Dr. Barry Kitch of the Massachusetts General Hospital Institute for Health Policy and Harvard Medical School, said in a news release from the hospital.

The study, published in the October Joint Commission Journal on Quality and Patient Safety, strengthens several previous studies that found "handoffs" can contribute to preventable injuries not resulting from a patient's underlying medical condition. Worries about the potential for handoff-related problems have grown since increased restrictions on the amount of time that residents can work result in even more frequent handoffs.

The results of the study, based on a 2006 survey of 161 medical or surgical residents at Massachusetts General, included the finding that more than half had reported at least one incident of handoff-related patient harm during their month-long inpatient rotations. About 12 percent of residents said handoffs resulted in major patient harm, including significant worsening of clinical status, prolonged hospitalization, disability or death. The same event may have been reported more than once, though, as the survey was anonymous, and details of the events were not sought.

The overall quality of handoffs during the rotation was rated "fair" or "poor" by one-third of the participants.

While nearly all the handoffs were conducted in-person, few were in a quiet, private setting, with a third of respondents reporting frequent interruptions. The problematic handoffs also reduced the residents' ability to provide complete and accurate information to patients, family members and other health care professionals, more than half the respondents reported.

"The study's findings that handoffs associated with patients' admission to the hospital were more likely to be problematic suggest specific areas to address," Kitch said. "The survey also confirms observations that handoffs are not routinely conducted in ways that minimize problems, such as in quiet, interruption-free settings. Further study of the causes and nature of handoff-associated events will help guide future efforts."

More information

The American Hospital Association has more about other issues facing hospitals.

Posted: September 2008


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