Safer Patient Handoffs

The Perils Of Un-Safe Signouts: What Happens When Physicians Fail To Communicate

June 18, 2015

In a recent piece that appeared in the New York Times (NYT) on June 18, 2015, a Massachusetts General internal medicine resident shares some of her experiences in the hospital that illustrate what can happen when physicians fail to communicate with each other. It has been well documented that poorly executed, non-standardized patient handoffs and signouts are linked to preventable medical errors and adverse events. In fact, communication failures between medical providers are also known to be a significant cause of preventable medical errors based on the analysis of closed malpractice claims against emergency medicine providers and physicians in training.

In the NYT piece, the author tells one story where she was communicating with the family of a patient hospitalized due to a serious gastrointestinal bleed due to her end stage liver disease. The physician had elicited from the family that the patient did not want any aggressive intervention to prevent the bleeding, but rather simply to be made comfortable. However, when the family meeting ended and the physician returned to the bedside, she found that in the interim, the patient had already undergone placement of a Blakemore tube to stem the massive bleed. The procedure had been done by one of the other consulting medical teams involved in the patient's care. Needless to say the physician was shocked and apologetic to the family that this had happened despite the family and patient’s wishes that it not be pursued. The author holds the story up as an example of the significant challenges multidisciplinary teams of doctors face when caring for severely ill patients.

The author then shares a second anecdote about a hospitalized patient with severe metastatic disease and multiple pathologic fractures that led her to present to the hospital for management of severe patient. The physician went in to see the patient one morning only to find the patient angry and frustrated with the fact that three different individuals had come in to see her that morning and none of them were on the same page; all of them had communicated conflicting information. For the remainder of the patient’s hospitalization they focused on having the patient’s primary team of admitting physicians synthesize the recommendations from all of the consulting medical and surgical teams and present the recommendations and plan of care more cohesively. The author found that this effort greatly decreased the patient’s confusion and frustration. This scenario is not uncommon in healthcare in the United States, be it inpatient or outpatient; and the situation is further exacerbated when multiple disciplines and teams of providers are involved in a patient’s care.

However, the good news is, research suggests that if a patient’s medical providers communicate better and more effectively, that the potential confusion and harm associated with frequent handoffs and signouts and coordinating care within large provider teams can be limited. Read the NYT piece here.