Teams need to talk. Facilities need to have a dialogue. Healthcare is moving in the right direction when it comes to improving the patient experience by improving patient safety. Recently, we saw the announcement and creation of the National Steering Committee for Patient Safety. This collaboration supports the Institute for Healthcare Improvement’s goal of reducing patient harm with one focus area being hand-off communications.
Communication is everything, especially in patient safety. In 2016, data showed communication failures led to nearly two billion dollars in malpractice costs spread over five years.¹
These four questions should be worked into your hand-off communication (HOC) plan, whether it’s between teams or for a patient moving from the hospital to an outpatient setting.
1. Who is the point person?
The Patient Safety Movement recommends an HOC team should recognize a “sender” and “receiver.” Now let’s take that one step further. We must make sure that not only are patients’ records shared, the receiver must fully understand what the patients’ needs are. That goes beyond just looking at a chart.
2. Is our process standardized?
This is so crucial because for many teams and health systems, they have their own process. In healthcare today, our patients are moving from emergency room to assisted living, back to the doctor for check-ups and sometimes back to the emergency room. A Harvard Medical School study tracked a 23 percent reduction in the rate of medical errors when the teams involved implemented a program called I-PASS, which gives healthcare workers the ability to easily recall the steps necessary for communicating important patient information during a shift change. The landmark study resulted in the realization standardization with proper education and tools can lead to less medical errors in hand-off without disrupting the workflow.
3. What could the patient need in the next 48 hours?
We can get so caught up in what’s happening now or looking at the chart in front of us. However, the laser focus can prevent us from sharing our clinician intuition. As caregivers we sometimes see the worst case scenario as we work with our patients, but we don’t always think to communicate it during hand-off.
4. What about medication?
In every Patient Safety Movement hand-off checklist, prescriptions and medication are on the assessment. This is another area that seems obvious, yet almost five percent of hospital patients experience an adverse drug event. This is one of the most common types of patient errors in acute care. On top of that, clinicians are tasked with recognizing opioid addicts as those numbers are on the rise. So don’t just enter the patient’s medication. Truly evaluate their reaction to the drugs. Make sure the dosage is accurate. We can’t miss this obvious mark.
Hand-off communication always sounds so simple, but it’s a bit more complex than we think. The data points to the numerous mistakes, but we have to take into account our bias, our language and our time to focus on standardizing our approach to minimize gaps in hand-off.
We have a quality improvement program and curriculum that helps staff stay engaged and improves the patients’ experience.
1. 5 CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015.