Keeping accurate, up-to-date patient records is a professional requirement and crucial to deliver excellent and safe patient care. U.S. based medical transcription companies play a key role in helping physicians across all specialties maintain accurate healthcare documentation. Up-to-date information about patient care, treatment, condition, and any recent or probable changes is necessary to prevent communication gaps during patient hand-offs. However, according to The Joint Commission (TJC), 80% of medical errors occur due to communication gaps, often within a handoff.
TJC defines a patient handoff as a “contemporaneous, interactive process of passing patient-specific information from one caregiver to another for the purpose of ensuring the continuity and safety of patient care.”
There are different types of handoffs:
- One unit to another
- Nursing unit to diagnostic area
- Patient discharge and transfer between facilities
- Between special settings, such as the emergency department and the general medical ward, between the operating room and the ICU, etc
The American College of Emergency Physicians considers the patient handover “the most dangerous point in a patient’s ED journey (www.ems1.com). Care transitions are risky as they give rise to opportunities to make mistakes, mostly due to communication gaps and lapses. According to a 2015 Report from The Risk Management Foundation of the Harvard Medical Institutions Inc., communication failures in U.S. hospitals and medical practices were major factors in 30% of its malpractice claims, with malpractice costs amounting to $1.7 billion in over five years. Enhancing communication during transitions of care can improve patient safety, reduce malpractice risk, and decrease healthcare costs.
Four Ways to Improve Patient Hand-off Communication
- Combination of verbal and written components: Hand-off communication can take place face-to-face, by phone, or via the medical record. Direct interaction between providers or face-to-face exchange of information is the preferred form of verbal communication as it involves discussion between the parties involved. The electronic report is a handoff tool within the electronic medical record (EMR) that staff can use to review information in an electronic format during the handoff process. Medical transcription outsourcing can help givers of information ensure robust information on the patient in the EMR. Digitized records allow clinicians who receive the information to recognize and review trends and identify important issues that needed to be acted upon. According to the American College of Obstetricians and Gynecologists, the most effective handoff of patient information includes both verbal and written components.
- Standardization: The TJC strongly recommends standardizing the hand-off process by implementing a suitable strategy. Two common hand-off transition interventions are:
- SBAR (situation, background, assessment and recommendation), and
- I-PASS (illness severity, patient summary, action list for the next team, situation awareness and contingency plans, and synthesis and “read-back” of the information)
Organizations can adopt either of these strategies, as long as the information provided is structured and thorough.
- Risk management: Identify situations in which handoffs occur in the course of patient care so as to spot risk points and identify critical opportunities for improvement. Based on this, a formal policy and procedure can be established for patient handoffs, including written and oral communication to support standardization (using SBAR or I-PASS). This will allow the development a specific strategy for handling hand-off communication data on a regular basis.
- Education: The entire healthcare team should work on assessing and enhancing communication skills.
- All team members – physicians, nurses, and others – should be provided with effective tools to ensure seamless communication exchanges.
- Staff should be trained in the patient handoff policy and step-by-step protocol
- Both individuals and teams should learn and hone the skills needed to handle routine and rare events as well as on-call situations. Essential skills include performing time-outs, speaking up, attentive listening, how to give and receive orders, and documenting accurately.
- Training together will ensure all members involved in the hand-off process develop teamwork communication skills
- Conducting periodic audits can ascertain whether staff is adhering to the designated procedure
- Retraining staff regularly and especially after a handoff error, and developing methods to minimize irregularities and correct errors
Timely, accurate, consistent and complete documentation is a critical component of effective communication in patient handoffs. Whether written or electronic, information related to transfer of patient care should the following key elements: pertinent demographic information, a brief history and the results of a physical examination, an active problem list, medications and allergies, pending test results, ongoing or anticipated therapy, key patient values and preferences, and any other critical information, which should be documented in the patient’s medical record if not already present (www.acog.org). Outsourced medical transcription services are a practical option to ensure accurate and up-to-date information regarding patient care.
Team work is essential to prevent communication failure. As the American Academy of Pediatrics points out in a recent article, “Fumbled handoffs do not have to happen. Clinicians working together to improve two-way communication is a game changer in patient care”.