What Impact Does Poor Handoff Have on a Patient?
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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.
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.
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.
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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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.