Medicine, Law and Policy
Keep Your Eye on the Patient
By Cinda Velasco, J.D.
Physicians who fail to communicate with each other when handing off responsibility for a patient put the patient at risk for injury and themselves at risk for malpractice.
A 53-year-old woman saw her family physician for pain and redness in her right first metatarsal after tripping and feeling a pop in her foot the previous day. The patient was given a probable diagnosis of gout and a prescription for Indocin. Four days later, she was admitted to the hospital by her gynecologist for a hysterectomy for endometrial cancer.
While hospitalized, she complained of pain in her foot. The gynecologist started her on Indocin. The next morning, her family physician changed the medication to Colchicine after the nurses called to report that her foot was swollen, red, and shiny and that she had a fever.
That evening, a nurse called her gynecologist’s partner to report the same symptoms. The partner ordered blood cultures and started the woman on Augmentin in addition to Colchicine.
On the morning of the third day post-op, the gynecologist discontinued the Augmentin and started the woman on Unasyn for a probable diagnosis of cellulitis of her foot. Later that morning, the nurses called the woman’s family physician to report two episodes of vomiting and no change in the condition of her foot. According to the hospital records, the nurses asked the family physician to come and see the patient. He did not and gave an order over the phone to discontinue the Colchicine and start the patient on Allopurinol.
The following day, the gynecologist consulted a different family physician about the woman’s foot. This family physician diagnosed severe cellulitis and ordered an X-ray and orthopedic consult to rule out osteomyelitis. Although the X-ray did not rule out underlying osteomyelitis, the diagnosis was confirmed by MRI four days later.
The patient ultimately had three surgeries for irrigation and debridement of the osteomyelitis in her foot and continued to have problems with recurring plantar lesions at the surgical site.
The woman sued her family physician alleging a delay in diagnosing the osteomyelitis. The case settled for $100,000.
Many physicians don’t realize that poor communication—failure to relay complete information, illegible handwriting, misunderstandings, and lack of communication—not only can result in frustration for patients and providers but also can lead to serious injury and malpractice claims.
According to Joint Commission data, poor communication is the biggest contributor to sentinel events, playing a role in more than 60 percent of such events in 2006. In 2005, it was a factor in almost 80 percent of sentinel events related to medication errors, more than 80 percent of those related to delays in treatment, more than 70 percent of such events related to operative and postoperative care, and more than 80 percent of perinatal deaths and injuries.
Although communication can break down at any point during patient care, it often happens during hand offs. These are the periods when patients are transferred from one hospital or hospital unit to another, when they’re moved from the hospital to a nursing home, when one provider is signing off and another is picking up call coverage, or when patients are being admitted to or discharged from the hospital.
A recent study by researchers from Mount Sinai School of Medicine in New York found that poor communication between inpatient and outpatient physicians frequently left primary care providers unaware of patients’ discharge needs. After evaluating nearly 700 hospital discharges, they found more than one-third of the recommended outpatient workups following a patient’s hospitalization were not completed. This often was the result of the discharge summary not including details of the recommended workup or the discharge summary not being available to the primary care physician at the time of the patient’s follow-up clinic visit. The investigators, who published their findings in the June 25, 2007, Archives of Internal Medicine, also found that changes to hospitalized patients’ medications may go unnoticed by their primary care physician after discharge. In approximately 11 percent of cases, patients had test results pending at discharge that turned out to be abnormal; their primary care physician was unaware of the results.
Why the Breakdown?
Researchers from Indiana University School of Medicine’s internal medicine residency program reviewed the literature on physician hand offs and uncovered barriers within their own program, a summary of which was published in Academic Medicine in December 2005. They found “a paucity of data in the medical literature on physician-to-physician communication” and little formal attention being paid to or education about this vital link in the continuity of patient care.
Tips for Ensuring Successful Patient Hand Offs
- Develop and implement transfer-of-care protocols.
- Standardize information that is relayed during hand offs.
- Update information in the same order.
- Educate all staff on change-of-shift and transfer-of-care protocols.
- Tell patients and their families whenever a new physician is taking over their care.
- Avoid transfers, discharges, or admitting patients during shift change.
- Make sure that the person taking over the care of your patient has adequate information to do so safely.
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However, in their own program, they found the major barriers to effective hand offs were 1) the physical setting, 2) the social environment, 3) language issues, and 4) the medium of communication. They noted that hand offs should be done in a setting that is reasonably quiet, private, and has appropriate lighting and writing space for taking notes. Often, hospital wards are crowded and filled with the sounds of televisions, overhead paging systems, other staff, and patients. They found that all members of a care team, including physicians, need to feel comfortable exchanging information and discussing treatment options with one another. In a hierarchical environment, residents or nurses may feel uneasy about approaching a physician or offering an opinion. They also noted the importance of nonverbal communication—eye contact, facial expression, posture, tone of voice, and gestures—in conveying a level of concern about a patient’s condition that might not come through in an email or on paper.
Several of those factors came into play in the case of the woman with the injured foot. The medical experts who reviewed this case agreed that the osteomyelitis could have been treated without surgery had it been diagnosed sooner. They pointed to the obvious communication lapses between the gynecologist, the family physician, and the nurses that led to the delay in diagnosis.
In that case, the nurses called and reported signs of infection to both the admitting gynecologist and the patient’s family physician. Unfortunately, the physicians failed to communicate in what should have been a joint effort to treat the patient. The experts who analyzed the case after the woman filed suit were critical of the family physician for giving orders over the phone and for failing to go to the hospital to see the patient in person. The family physician said he did not examine the patient because the gynecologist did not request a formal consult. However, the nurses never communicated to the gynecologist the fact that the family physician didn’t see the patient.
Preventing Fumbles
There is wide variation in the quality and amount of information physicians give each other and other care providers when they are handing over the care of a patient.
In 2006, the Joint Commission, as part of its national patient-safety goals, added a requirement that hospitals seeking accreditation standardize their approaches to hand-off communication. This may be done differently depending on the unit or setting, type of patient, and providers involved. However, there must be an opportunity for the recipient of the information to ask questions and get clarification.
Hospitals are taking various approaches to fulfilling this requirement. Those in the Oakland, California-based Kaiser Permanente system have adopted the Situation–Background–Assessment–Recommendation (SBAR) approach. SBAR is an acronym for framing communication that is especially useful for discussions that require another provider’s immediate action. For example, if the physicians and nurses who treated the woman with the injured foot had used SBAR, they may have called the family physician directly to explain the patient’s condition and their concerns. Had the nurses taken the time to explain the entire situation to the family physician, perhaps he would have come to see the patient rather than let the gynecologist consult with a physician who had no knowledge of the patient or her history. Providers have found this communication technique encourages dialogue that is clear, unambiguous, and essential to developing teamwork and fostering a culture of patient safety. You can find more information about SBAR at www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/
SBARTechniqueforCommunicationASituationalBriefingModel.htm.
Strategies for Better Communication
Regardless of the situation, the critical issue in handing off a patient is that information is clearly communicated to the physician receiving the patient so he or she can provide safe, effective care. Taking the following steps can help ensure that happens:
Set the right tone. Create a culture that allows and welcomes discussion about patient care. If all the partners in a practice believe that communication during hand offs is important, they will encourage other providers and staff members to ask questions or seek clarification, and they will ask for pertinent information when they are taking over care of patients. Also, avoid doing hand offs in settings where distractions such as loud noises and frequent interruptions occur, and allow enough time for questions. Encourage follow-up phone calls to clarify instructions and prevent post-discharge errors.
Refer to the chart. One advantage of an electronic medical record (EMR) is that the patient’s medical chart is readily available. If your practice does not have an electronic system or if you’re handing off a patient to a physician or provider who cannot tap into your EMR system, be sure to provide copies of the critical portions of the record to the receiving staff when transferring patients between care settings.
Be specific. When handing off patients, provide details that are pertinent to the individual patient. Vague descriptions such as “she’s unstable” may not accurately reflect the patient’s status. Specific information such as “she’s hypotensive (90/50) and tachycardic (140)” is more informative. Also, use a system that will help you remember all the information you need to pass along to the next physician. Even something as simple as a sign-out list or status display that includes information such as the patient’s name, diagnosis, current status, treatment plan, pending lab or test results, and any ongoing concerns can help to ensure all information is available.
Verify information, don’t make assumptions. Verifying information is a critical part of the communication process. Joint Commission standards require that the provider assuming care of a patient have a chance to ask questions and get clarification. Be sure the patient and all consulting physicians know which provider will follow the patient and be responsible for the big picture in terms of a patient’s care. Communicate this to the patient and his or her family members as well. Also, discuss who will follow up on pending lab and other test results, and who will pass along that information to the patient.
Be vigilant during shift changes. Shift changes are often the time when medical errors and/or omissions occur. Thus, they are dangerous times to be discharging, transferring, or admitting patients. To avoid errors, be meticulous about reporting. Whenever a patient is transferred or a physician is going off duty—even if only for a break—the physician who is taking over care should get a report that includes information about the care provided for the patient, procedures or tests that need to be followed up on, and the plan for care. Such communication is the responsibility of both parties. The physician handing off the patient needs to tell the provider who is taking over care what has happened and what to expect. On the other hand, the provider assuming care should ask for additional information or clarification when necessary.
Avoiding Liability
Patient hand offs are ripe for communication breakdowns that can lead to delayed diagnoses and treatment, and even patient injuries—all of which can put physicians at risk for liability claims. To reduce the chance of errors, physicians handing off a patient should go over information with the provider assuming care in a face-to-face setting using a systematic approach.
When it’s not possible for these discussions to take place in person, physicians need to be extra vigilant in making sure they pass along all necessary information. Using a standardized list can help ensure you’re passing along important details and doing so in a clear, consistent way. Whether writing emails or making phone calls, make sure you have enough time and that you do the work in a quiet place that is free of distractions. And regardless of how you share information, make yourself available to answer any questions from the physician who is taking over care. MM
Cinda Velasco is an attorney with Midwest Medical Insurance Company in Minneapolis.