Avoiding the Dangers of a Hospital Shift Change

Everyone remembers a classroom where the students were assigned seats alphabetically by last name. Often, the kids with the W, Y and Z names got stuck at the back of the class. (Some, of course, relished this less visible position; others preferred to be closer to the teaching action.)

Generally, such seating charts helped the teacher connect faces to names, and keep better track of who’s where. But what if the kid named Zimmerman needed extra attention, what if that kid didn’t see well?

In health care, like classroom management, implementing a certain process just to make life easier for the people conducting it can mean that the people you’re trying to help fall through the cracks. A story published recently by Kaiser Health News (KHN) looked at how this happens during hospital shift changes.

Called the “handoff,” it’s the drill doctors use to inform the incoming shift about the status of the patients the previous shift has attended. As described in a research letter published in the Archives of Internal Medicine, “Handoffs in hospitals have been widely recognized by both regulators and researchers as a locus of potential communication failure, with substantial risks to patient safety and quality of care. By conservative estimate, there are over half a billion patient handoff discussions annually in U.S. hospitals.”

Dr. Michael Cohen of the University of Michigan conducted a handoff study of 262 patients at a hospital in Ontario, Canada. The sampling, of course, is limited, but in an interview with KHN, Cohen called the process he observed “a very common practice” in American hospitals.

In handing off treatment in the intensive care unit (ICU) at the Canadian hospital, doctors didn’t organize their discussions based on how ill patients were, but by their bed numbers. Is anyone surprised that the docs spent more time talking about patients at the beginning of the list than those at the end?

As Cohen described it to KHN, “We call it the ‘portfolio effect.’ It’s the effect that people tend to spend excess time on the early cases on the list. … Because the total time is limited, that means less time [to discuss the cases] at the end.”

What if the guy “at the end” experienced complications during the last shift, what if he presented with some really odd symptoms, what if a bunch of doctors were called to consult? Such patients might get shortchanged-Cohen’s study alluded to previous research that indicated miscommunication during handoffs threatens patient safety and might contribute to medical errors that otherwise could have been prevented.

Improving handoffs is pretty simple, Cohen said. “Physicians and nurses have to pay attention at the start of the handoff session to which cases require the most discussion time. Under the [federal] health care act and the stimulus package, hospitals are being encouraged to adopt electronic health records. [They] can be adopted to support a better picture of which patients need the most discussion.”

In better allocating handoff time, doctors and nurses should be aware not only of issues arising in the outgoing shift, but also the in the ones that preceded it-patients don’t always heal or worsen predictably.

If you or a loved one is an inpatient, ask your attending doctors and the hospital’s patient representative (also called patient service representative or patient advocate) about their handoff procedure. Be specific:

• How is my care transferred from one shift to the next?
• How do I know all relevant information will be communicated and understood?
• How do I know all of the information the previous shift entered into the digital records is reviewed by the new shift?

Unless your hospital has developed a handoff procedure addressing the most common shortcomings, you probably can’t get complete or confirmable answers to these questions. But the fact that you raise them alerts the staff that you’re concerned, and paying attention. For more information about how to make a hospital stay safer and more successful, see my newsletter “Protecting a Loved One in the Hospital,” and “A Safer, Healthier Hospital Stay.”