Safety Concerns for Patient Hand-offs

With any communication, it’s important to provide clear, understandable information. If you misunderstand your spouse’s instructions for heating up dinner, a little aggravation boils up along with the food. However, communication issues can lead to much more than an aggravation when your health is at stake. Effective communication among medical staff is essential when patient care is transitioned from one team to another – frequently referred to as hand-offs. Any gaps in communication during these transitions can impact patient health, sometimes quite seriously. In fact, one study estimates that 80% of serious medical errors involve miscommunication during the transition between medical providers. That statistic alone should convince you to pay attention to the safety concerns of patient hand-offs. So, what can you do to reduce your risk of problems during transitions of care for yourself or a loved one?

What exactly is a “hand-off” or “transition of care”?

This post covers transitions of care which involve the physical transfer of a patient from one location to another. However, it’s important to note that transitions of care are a type of hand-off. In healthcare, the term hand-off relates to any situation where the care of a patient is transferred from one provider team to another. This includes daily staff shift changes, as well as moving the patient within a facility or to a new facility.

This post focuses on care transitions when the care of a patient transitions from one location and provider team to another, when:

• Moving a patient from one healthcare setting to another, including movement within and between any of the following: hospitals, outpatient practices (doctors’ offices, surgical centers, treatment centers, etc.), and long-term care facilities.
• Discharging a patient to home with an order for follow-up care, after a hospitalization or visit to the emergency department.

Although there are safety concerns for patient hand-offs of all types, experts believe the most problematic transition is when patients leave the hospital to receive care in another setting or at home.

Effective communication is key during hand-offs due to transitions of care.

When patients transition from one provider team to another, communication between providers regarding a patient’s diagnosis, treatments and care is essential for a successful transition. The providers in the new setting, which can include doctors, nurses, home health aides and family members, need the opportunity to ask questions, seek clarification and confirm they understand the information provided.

Unfortunately, poor communication is a common and serious concern for patient hand-offs. Communication gaps can cause medical errors, including delays in treatment, inappropriate treatments and even deaths. Additionally, communication gaps can lead to longer hospital stays, higher hospital readmission rates, and increased costs.

Furthermore, transitions to different facilities can introduce additional difficulties. For instance, many Electronic Health Record systems cannot share information with other facilities, and sometimes can’t even communicate with different practices in the same hospital! Additionally, every practice and facility have their own culture and way of managing care.

What makes communication difficult around transitions of care?

There are many opportunities for communication breakdowns throughout the transition process. Unfortunately, care providers do not always effectively or completely communicate important information among themselves, to the patient, or to those taking care of the patient at home in a timely manner.

A project by the Center for Transforming Healthcare identified the following risk factors related to communication issues around transitions of care:

• Different expectations between senders and receivers regarding patients in transition.
• The organizational culture, including a lack of teamwork and respect, may not promote successful hand-offs.
• There is a lack of standardized procedures for transitions in care.
• Inadequate amount of time available to plan and execute a successful hand-off, resulting in a low-quality information exchange.
• In many cases, no doctor or other healthcare provider takes full responsibility for a patient’s healthcare across various settings and providers, leading to a lack of care coordination.
• Healthcare providers often fail to communicate or coordinate care when multiple specialists are involved in a patient’s care.
• Providers may fail to make sure the subsequent healthcare setting has sufficient knowledge and resources at the facility to care for the patient when he/she arrives.

Communication issues arise when patients go home from the hospital.

When patients return to their homes after a hospital stay, their ability to manage their health relies on their understanding of their diagnoses, treatment, and follow-up care. However, understanding this important information can be difficult. Why? Because healthcare providers may not effectively or completely communicate important information to patients, family caregivers or home health aides.

According to the Center for Transforming Healthcare, the discharge period can involve communication problems between providers, patients and families, including the following:

• Patients or family/friend caregivers may receive conflicting recommendations, confusing medication regimens, and unclear instructions about follow-up care.
• Some healthcare provides exclude patients and caregivers from transition planning.
• Patients may lack a sufficient understanding of the medical condition or the plan or care, causing them to think the care plan is not important.
• Patients/families may lack the knowledge and skills to follow the care plan.
• Providers may fail to make sure the patient and/or family has sufficient knowledge and resources at the patient’s home after discharge.

Older patients are at highest risk of safety concerns related to patient hand-offs.

Patients over 65 are at serious risk of adverse events after a hospitalization. (When medical care causes patient harm or injury, including the failure to provide appropriate care, it’s called an adverse event.)  There are many reasons hospital discharges pose risks for older patients. For instance, illness and/or fasting before surgery can lead to malnutrition. And, the change in surroundings, sleep disruptions and anesthesia can all lead to delirium. Furthermore, a lack of physical activity, including walking, can lead to muscle deconditioning. Lastly, changes in an older patient’s medication regimen are common during hospital stays. All these factors combine to increase the risk of adverse events for older patients upon hospital discharge.

Transfers from hospitals to long-term care facilities are high-risk.

Certainly, many residents of long-term care facilities (such as nursing homes) have health issues that can lead to hospitalizations. In fact, the most recent data available shows that in the US, about 25% of the residents of long-term care facilities are admitted to a hospital each year, most of whom return to their long-term care facility after their hospital stay.

Although hospitalizations can improve their health issues, transferring these patients back to their long-term care facility after a hospital stay is a dangerous time. Researchers evaluated the period of transition from hospital to nursing home for 555 long-term care residents, who accounted for 762 hospital discharges. The study found that adverse events occurred in 37% of the cases. And, they found that almost 50% of the events were serious, life-threatening, or fatal. Moreover, of the adverse events, they deemed that 70% of the problems could either have been prevented or alleviated. The most common events were skin tears, pressure sores, falls, healthcare-acquired infections, and adverse drug events.

Interestingly, the study found that almost 25% of adverse events occurred either on the day of discharge or the next day, indicating that some residents were likely discharged too soon. Certainly, strategies to assess a patient’s readiness for discharge may reduce the risk of adverse events. Additionally, the authors note that transition of care issues may be minimized by:

• Promoting effective communication and coordination of care between the hospital and long-term care facility, including standardized report of events.
• Strengthening person and family engagement as partners in patient care.

How can hospitals and healthcare organizations reduce the safety concerns of patient hand-offs?

Hospitals and other healthcare organizations must create and follow steps to avoid miscommunication and associated errors. The Joint Commission suggests that all healthcare settings establish the following seven “foundations” to assure safe transitions from one health care setting to another:

• Leadership support.
• Multidisciplinary collaboration.
• Early identification of patients/clients at risk.
• Transitional planning.
• Medication management.
• Patient and family action/engagement.
• Transfer of information.

One example of a program designed to help hospitals better manage transitions is the Hand-off Communication TST (Targeted Solutions Tool™) by The Joint Commission Center for Transforming Healthcare. The TST provides a step-by-step process to measure and improve transitions. According to the Joint Commission, this tool has successfully helped organizations increase successful transitions while improving patient, family and staff satisfaction.

What can you do to minimize the safety concerns of patient hand-offs?

There are steps you can take to reduce the risk of errors during transitions in care:

• Ask your hospital if they follow the Joint Commission’s TST guidelines or use another program to reduce the risk of errors at care transitions.
• Participate in the transition planning process. Importantly, speak up if something doesn’t seem right.

For transfers to another department or to a different facility:

• Ask the doctors in both locations to speak with each other before the transfer.
• Ask the medical team to send the clinical records to the new staff before the transfer.
• Bring all of the patient’s medical records, including detailed medication lists, to the new location. Share these records with the new staff.
• If possible, avoid having a very sick patient move to a new location late in the day.

For transitions to home from a hospital stay or ER visit:

• Read Tips for Hospital Discharges for a tips to make a transition home easier and safer.

A note about shift changes.

Certainly, the daily shift changes on hospital floors involve transitions of care from one team to the next, providing a frequent opportunity for communication errors. As a patient or family caregiver, you can take steps to minimize the chance of safety concerns associated with patient hand-offs during shift changes:

1. At any point in a hospital stay, it’s important to speak up if something doesn’t seem right. Now is not the time to be bashful.
2. Participate in the bedside (or hallway) meetings that occur during shift changes. Take notes, ask questions and speak up as needed. For more information, read The Benefits of Participating in Hospital Rounds.
3. Keep a list of medications with the patient. To avoid medication errors, never take unfamiliar medications. If you suspect an issue, speak up. For more information, read Medication Errors in Hospitals – How Can You Protect Yourself?
4. Keep a bedside notebook with diagnosis, test results, treatments and notes from conversations with doctors. Read Why Take Detailed Notes at Doctor Appointments?

Learn more…

Read these blog posts to learn more:

• Where to Recover After the Hospital?
• How to Sleep Better in the Hospital.
• What’s a Hospitalist? Do You Need One?