Hand-offs are dangerous, but fixable

And I'm not talking football. It seems by the day, more hospitals are implementing simple innovations and thus reducing dangerous errors. A big reason why they're doing so is the push from the JCAHO, the body that accredits hospitals & regulates them.

The push continues. The JCAHO recently reported that communication breakdown is "the single largest source of medical error," and it's now "for the first time [establishing] standards for hand-off communications," the communication between outgoing & incoming staff.

The stakes are high, as hospitals that fail to comply with Joint Commission patient safety standards risk losing accreditation, which is often required for reimbursement from Medicare and private insurers.

Luckily, "a few hospitals and health-care quality groups have been ahead of the pack, borrowing communication strategies used in aviation and the military..." One such group is the Institute for Healthcare Improvement, which has been promoting a "communication model known as SBAR -- an acronym for Situation, Background, Assessment and Recommendation," which was developed for use in nuclear submarines. Kaiser & the VA are also ahead of the pack.

"A hand-off is a precision maneuver, but in medicine it has been left to happenstance," says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.

What's the danger in hand-off errors? Well, they run the gamut "from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren't aware of a "do not resuscitate" order," says an internist at Yale University and the VA.

The most remarkable example of how communication models like SBAR can reduce fatalities and other medical injuries, as reported in the WSJ article "Hospitals Combat Errors at the 'Hand-Off': New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift," is at OSF St. Joseph Medical Center.

John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.

At first, nurses and other staffers were hesitant to provide the "R" -- for recommendation -- to physicians, Dr. Whittington says, but doctors were asked to encourage staff to do so. By last year, the briefing format was used by more than 98% of nurses and the rate of adverse events -- defined as an unexpected medical problem that causes harm -- fell to 39.6 from 89.9 per 1,000 patient days, Dr. Whittington says.

It's amazing how powerful this small inexpensive change in the way things are done in the hospital truly is. You would think hospital leaders would be all over it. Think again.

"It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine," says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network. Seton began using the SBAR model in its four labor-and-delivery units in January 2005, as part of an effort to eliminate complications for patients and make it easier for nurses to quickly brief each other and doctors.

Still, people inside hospitals are changing. And one of the catalysts of this change is technology, namely the electronic patient record system.

Brigham and Women's Hospital in Boston, for example, has used a computerized sign-out system for several years, and is developing a more-advanced version for the sickest patients in the ICU. David Bates, chief of the Division of General Medicine, says electronic systems are the only way to ensure the safe hand-off of large numbers of patients in a busy hospital, "so a standard set of information can get exchanged every time."

As part of its transition to electronic medical records, Kaiser has developed a Nurse Knowledge Exchange computer program, which allows departing nurses to create customized electronic reports on patients for the incoming nurses, such as lab results or medication changes. But the nurse coming on duty also makes bedside rounds with the outgoing nurse, and engages patients when possible in a discussion of treatments and progress.

It's awesome that a basic innovation in process, coupled with better info technology, are saving many more lives with little additional cost.