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What Impact Does Poor Handoff Have on a Patient?

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Clinical handover is much more than the doctor and nurse interaction at the beginning and end of a scheduled time. It is the conversation that ensures information is passed on to the appropriate person on a timely manner and is carried out appropriately. The effect of poor clinical handover is an ineffective system at best and patient death at worst

The concern of enhancing clinical handover is gaining escalating attention as inpatient stay as well as medical working hours is reduced, whereas at the same time patient acuity augments. Poor clinical handover is connected with discontinuity of patient care and medical errors.

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One of the challenges that nurses face during the handoff is absence of a standardized tool to facilitate nurses’ handoff process. The basic reason for the lack of standardized tool is the variability in the patient care need and the clinical areas’ requirement. Keeping in mind the importance of this issue, quality improvement initiatives by World Health Organization (WHO) and JCAHO mandates the standardization of the handoff process as a key to prevent the adverse events in the clinical care (Pesanka et al., 2008). For this very reason, many recent studies have reported implementation of tools in different clinical setting like in preoperative care, surgical care (Sandlin, 2007), and in emergency room (ER)

In general, kardex is the most common nursing handoff tool that is used in most of the hospitals worldwide (Crabtree et al., 2009). Importantly, kardex provides structural guide to share patient information during handoff but does not provide a particular sequence for the information sharing. For this reason, it is observed that nurses share handoff information in different sequence and this may result in the omission of important information during handoff. Moreover, it is also observed that the kardex are not always utilized appropriately by nurses and neither are they reviewed or updated in timely manner. In addition, incomplete documentation on the kardex is also reported.

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Our expanding knowledge base and technological advances in health care spawn additional categories of health care providers and specialized units designed for specific diseases, procedures, and phases of illness and/or rehabilitation. This dynamic, ever-increasing specialization, while undertaken to improve patient outcomes and enhance health care delivery, can contribute to serious risks in health care delivery and promote fragmentation of care and problems with handoffs. (Solet D, Norvell JM, 2005)

It is ironic that as health care has become more sophisticated due to advances in medical technology focused on saving lives and enhancing the quality of life, the risks associated with the handoffs have garnered attention in the popular press and reports from health care organizations and providers. (Beach C. 2006)The hazard that “fumbled handoffs" pose to patient safety and the delivery of quality health care cannot be ignored. Ineffective handoffs can lead to a host of patient safety problems; research1 and development of strategies to reduce these problems are required.

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By and large, in order to help healthcare professionals navigate the tradeoff between efficiency and thoroughness, hospitals can build a strong culture of teamwork across units, while using other organizational development activities to bind its members to a common vision and shared mental model. The interactions between the different types of transitions we showed in this study suggest that spillovers into other aspects of patient safety are likely to occur. More importantly, defining patient safety culture in a specific form (transitions of care) attenuates ambiguity so that stakeholders can more clearly identify with the goals and process of patient safety improvement programs.

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Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. Int J Qual Health Care. 2004;16(2):125–132.

Solet D, Norvell JM, Rutan GH, et al. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094–1099.

Beach C. Agency for Healthcare Research and Quality Web Morbidity & Mortality Rounds: Lost in transition. February , 2006.

Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826–833.

Cheah LP, Amott DH, Pollard J, et al. Electronic medical handover: Towards safer medical care. Med J Aust. 2005;183:369–372.

Gandhi TK. Fumbled handoffs: One dropped ball after another. Ann Intern Med. 2005;142:352–358.

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