In Practice: Doctors could learn something about medical handoffs from the Navy by Rahul Parikh was an article that ran April 18, 2011 in the Los Angeles Times and the article illustrated a great point that I thought was worth sharing.
The author shared this story: During a night on call, a patient he was “cross covering” — caring for during the night shift — went into cardiac and respiratory arrest. Dutifully, the resident and his team began to resuscitate the patient.
They performed CPR for well over a minute. Then, suddenly, they stopped — and not because the patient was beyond saving. Another team member had reviewed the patient’s chart and learned he was not a “full code.” The patient, in other words, had requested as part of his treatment plan that he not be revived should his body fail. Trying to save him had been wrong.
This mess-up — like many other errors in medicine — happened because of a botched handoff, the process by which a physician going off duty transfers responsibility of a patient to another doctor. In this case, the doctor going off duty had failed to communicate the patient’s code status to the resident taking over his care.
Handoffs are the glue that holds together a patient’s care in the hospital. Yet traditionally they have been a disorganized — even sloppy — process. During my residency, we used paper and pencil to keep track of patients and transfer their care to others. We kept these pieces of paper folded in our pockets and constantly updated them by erasing and rewriting on them.
Over the course of a day and a night on call, that pristine piece of paper got tattered and torn, confused with scribbles, eraser marks and shorthand made by many doctors. Somewhere on that paper was the right information, but it wasn’t always easy to find.
It was probably more luck than smarts that saved me from making any major mistakes through my own imperfect handoffs. Statistics show that some 80% of adverse events in hospitals involve communication problems between healthcare professionals, often in the form of a fumbled handoff. A review of surgery malpractice cases from 1991 to 2000 reported that inadequate information-sharing among team members was the primary trigger for lawsuits.
Many doctors seem to view handoffs as an annoyance, even with disdain. Often, the question doctors are asking when they hand patients off isn’t “How do I get this right each time so that my patients stay safe?” but “How do I get this done so I can get out of here fast?”
The reasons go on and on, but the tough question is how to make handoffs safe and effective. In their search for solutions, many patient-safety experts are looking for answers outside of healthcare.
Now I don’t believe there’s any revelation in the information shared by the author above. Most of us in health care realize the handoff procedure is often less than perfect. The article got interesting when the author began to talk about practices other industries utilize to reduce communication lapses and how those practices might translate to health care.
In the navy every person on a nuclear submarine must show they are able to use the phone appropriately before they are allowed to do anything else. It seems odd that on a ship with a nuclear generator and weapons capable of wiping out a town the size of Clinton, the first thing that a new crew member must do is prove he or she can use the phone.
The reason the phone is so important is because there is protocol to follow each and every time the phone is used. Every time the phone is used any order must be received, acknowledged and read back. If not, the person on the other end of the phone is instructed to say ‘Wrong’ or ‘Repeat Again’ until done right.
The other practice that occurs at shift change on the nuclear submarine that can be utilized in the health care hand off is the practice of signing out issues and events on one persons watch to another’s the same way from shift to shift and day-to-day. Everyone completes the sign out the same way, each and every time. There’s a lot to be said for protocol and consistency in reducing errors.
I’m a pilot and the first lesson I received when doing my flight training was the use of a checklist. All pilots, whether they’ve been flying 3 years like me or 30 years like Dr. Clouse, are supposed to review a checklist before taking off. The checklist helps to ensure the pilot has completed any task required for safe flight, things as simple as turning the power switch on to things as important as verifying that the fuel supply is open.
You would think no one would forget to open the fuel supply or check the fuel level prior to take off but every year there are plane crashes and emergency landings because a pilot failed to use a checklist and complete every required task prior to take off.
Most health care organizations have worked to improve the hand off of patient information. At GVMH we use the SBAR protocol and we have a report process that occurs at shift change. We do a great job with our hand off process but at GVMH, and all health care organizations, we can always do better and maybe we should learn from other industry instead of trying to reinvent the wheel.