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Hospital hand-offs and medical errors

People lie in beds on the verge of death, with tubes stuck into their bodies at all angles, respirators forcing life-giving oxygen into their inactive lungs, loved ones holding their hands at their bedside.

What is striking is the impassiveness and professionalism of the staff going about their job, making sure that the bio-chemical reactions of their patients are kept stable as much as possible. I guess it has to be like that as a coping mechanism for the staff in order to cope that with day after day, patient after patient. If you got emotionally involved in an ICU, where so many people end up not making it, you probably would burn out in a short period of time.

The problem is that despite this admirable professionalism, the sheer volume of patient information transmitted as each shift of staff comes in to replace the next means there is lots of opportunity for mistakes to occur. Apparently, such hand-offs take place 4,000 times a day in the hospital, or 1.6 million times per year. Lots of stuff slips through the gaps. But this situation is made much worse by the fact that there is no formalized data transfer system for what is known as “patient handoffs”, where patient data and updates are passed from one clinician to another. It is ad-hoc and lacking structure to a frightening degree.

Taking into account how critical it is to have right information at the right time being transferred in an ICU precisely as is there are very few tools yet to reduce risks during the hand-off process. This area of a hospital life has been always associated with medical and medication errors during geographical transitions (from one floor or department to another), care transition (hospital admissions), staff shift rotations during the day and night and a variety of other transitions that allow for the possibility of miscommunication.

That patient hand-offs are ad-hoc, disorganized, inefficient and have to be improved has become very clear for the Joint Commission Center for Transforming Healthcare. Patient hand-offs are one of the improvement projects the Center embarked on August 2009 in order to reduce the mistakes and improve delivery of healthcare because lives are at stake especially in critical units such as ICU. Better tools are needed.

I will pick up this topic in following posts!

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