What are Patient Handoffs and Why Does Your Life Depend on Them?

Patients’ lives depend on how well doctors communicate to their patients and to one another.

Doctors are sometimes required to see as many sixty patients in a single day. Each patient is entitled to care catered to his or her medical needs. But doctors, nurses, and other clinicians are receiving information about dozens of patients’ vital signs, symptoms, and potential treatments at any given moment.

Maintaining this information and accurately communicating it to other medical providers is critical for patient safety.  Unfortunately, this information is often miscommunicated during transitions of care and at discharge.

Why are Transitions of Care Important?

What exactly is a ‘transition of care’? A transition of care occurs when a patient moves between healthcare professionals. When a patient is referred by a primary care physician to see a specialist, a transition of care takes place, for example. A transition of care can also be when a doctor, nurse, or any other healthcare professional changes during a shift change on the job.

Other transitions include when a patient is transferred from one medical facility to another—such as when a patient is moved from a small to a larger hospital or when a patient is sent to a rehabilitation facility after a hospital stay.

Medical errors are a leading cause of death and injury in the United States. Between 200,000 and 400,000 people die each year from medical errors, making it the third leading cause of death in the U.S.  Medical researchers estimate that the number of patients who are seriously injured every year because of medical errors is 10 to 20 times that figure. Medical errors are a common source of wrongful death lawsuits.

Serious medical errors include medication errors and overdoses, delayed diagnosis and misdiagnosis, and preventable surgical errors.

It is estimated that 80 percent of the most serious medical errors can be linked to communication between clinicians, particularly during transitions in patient care. For example a handoff related error might occur if information about a diagnostic test (like an x-ray or MRI) is not communicated correctly between physicians at shift change, resulting in the test being delayed or not performed at all. Other common communication breakdowns relate to medication errors.  Medication errors are one of the largest sources of preventable medical errors in the United States.

According to the Joint Commission (the body that accredits most hospitals in the U.S.), every transition of care should include medication reconciliation. Medication reconciliation is the process of creating an accurate list of all medications a patient is taking—including by medication name, dosage, manner / route of administration, and frequency—and comparing it to any orders, including physician’s, transfer, and discharge orders for accuracy at all transition points within the hospital.

Despite these calls for medication reconciliation, a report issued by the United States Pharmacopeia found that 66 percent of medication errors occurred during the patient’s transition or transfer to another level of care, 22 percent occurred during the patient’s admission to the facility, and 12 percent occurred at the time of discharge. The majority of these errors were due to failure to provide the medication and prescribing errors. Other types of errors reported were wrong drug, wrong time, extra dose, wrong patient, mislabeling, wrong administration technique, and wrong dosage form.  Each of these failures is the result of communication errors.

Causes of Errors

The Joint Commission has identified several factors that contribute to breakdowns in transitions of patient care.  The most common causes of errors in transitions of care are:

Communication Breakdowns

Care providers do not effectively or completely communicate important information among themselves, to the patient, or to those taking care of the patient at home in a timely fashion.   The communication method—whether verbal, recorded, or written—is ineffective.

For example, the Center for Transforming Healthcare’s hand-off communication project found these risk factors among those relating to communication:

• The expectations differ between senders and receivers of patients in transition;

• The medical culture does not promote successful transitions (e.g., lack of teamwork and respect);

• There is an inadequate amount of time provided by the institution for successful transitions; and

• The institution lacks standardized communication procedures in conducting successful transitions of care.

Communication errors are a common cause of medical errors in hospitals.

Patient Education Breakdowns

Medical providers’ failure to fully educate patients and their family members, or anyone responsible for the patient’s care, about the transition process is a leading source of medical mistakes. The following are common breakdowns in patient education:

• Patients or family / friend caregivers sometimes receive conflicting recommendations, confusing medication regimens, and unclear instructions about follow-up care.

• Patients and caregivers are sometimes excluded from the planning related to the transition process.

• Patients may lack a sufficient understanding of the medical condition or the plan of care. As a result, they may not understand the importance of following the care plan, or lack the knowledge or skills to do so.

Accountability Breakdowns

In too many cases, no physician or medical institution that takes responsibility to ensure that the patient’s health care is coordinated across various settings and among different providers.  This frequently results in medical errors in the following ways:

• There is no point person who is responsible for coordinating the patient’s care throughout the process from provider to provider;

• Medical providers—especially when multiple specialists are involved—don’t coordinate care or communicate effectively, which creates confusion for the patient and those responsible for transitioning the care of the patient to the next setting or provider; and

• There is often limited discharge planning and risk assessment. Steps are not taken to assure that sufficient knowledge and resources will be available—either at home or at the next setting—to the patient upon discharge.

Errors Involving the Elderly

Because the elderly often see numerous physicians and take multiple medications, they are at an increased risk of injury from medical errors.

Errors in handoffs and transitions of care are especially prevalent for the elderly and those in long-term care.  Consider the following statistics identified by the National Transitions of Care Coalition:

• Between 41.9 and 70 percent of Medicare patients admitted to the hospital receive services from an average of 10 or more physicians during their stay;

• Among hospitalized patients 65 or older, 23 percent are discharged to another institution, and nearly 12 percent receive home health care;

• Among patients discharged from a skilled nursing facility, 19 percent are readmitted within 30 days; and

• On average, patients 65 or older with two or more chronic conditions see seven different physicians within one year, accounting for 95 percent of Medicare expenditures.

The need for coordinated and accurate communication is a matter of life and death for the elderly.   Elderly patients often visit multiple care facilities and take long lists of medications for multiple conditions. Elderly patients are at an increased risk of injury and death from hospital and medical errors.

If there is a practical solution, researchers may be on the brink. In a recent study conducted at UC San Francisco, researchers found that when healthcare providers incorporated more efficient communication practices, there was a 30 percent decrease in injuries suffered because of medical error.

Michael A. Hill is an accomplished trial lawyer focusing on representing individuals who have suffered life changing injuries, including stroke and death.   Michael practices in state and federal courts around the country and has argued cases in front of numerous appellate courts, including the Ohio Supreme Court.  Michael has recorded several seven figure verdicts and settlements.  Michael is a regular speaker for lawyers concerning litigation and trial practice.  Michael is a member of The National Trial Lawyers Top 40 under 40, Top 10 Nursing Homes Lawyers, Top 25 Medical Malpractice Lawyers, Super Lawyers: Rising Star, and Multi-Million Dollar Advocates Forum.

Michael is from Flint, Michigan and received his undergraduate degree from Oberlin College in Oberlin, Ohio, where he was introduced to his wife, Hilary.  Michael received his law degree from Case Western Reserve University School of Law where he graduated Magna Cum Laude.  Michael and Hilary live in Lakewood, Ohio. Michael is a Partner and founder of Eadie Hill Trial Lawyers.