What’s New in the
Patient Safety World
December 2018
Handoffs Don’t
Predict Everything
Arguably, the most important feature of the “signout” or handoff is the ability to anticipate events that might potentially occur on the next shift. But how good are we at anticipating actual events? A new study in an ICU setting provides some insight.
Dutra and colleagues in Brazil (Dutra 2018) analyzed 44 day-to-night handovers between intensivists in an ICU. They surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning.
Nighttime clinicians correctly identified only 53% of diagnoses and 40% of goals shortly after the handoff. The positive predictive value of both daytime and nighttime clinicians for anticipating clinical events at night was low (13% vs 17%). Daytime clinicians were more sensitive (65% vs 46%) but less specific (82% vs 91%) than nighttime clinicians in anticipating clinical events at night. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses.
The authors conclude that the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Furthermore, they suggest that handovers could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.
A previous study of pediatric resident handoffs (Borowitz 2008) showed similar problems in anticipating events. 31% of surveyed resident physicians indicated something happened while they were on call for which they were not adequately prepared. And in 82% of those instances, they indicated there was information they did not receive during sign-out that would have been helpful to them in caring for a patient overnight, And, of those, they indicated the situation should have been anticipated and discussed during sign-out in 82.5% of cases. Perhaps surprisingly, residents were no more likely to report events they were unprepared for when they were “cross-covering” at night than when they were members of the general pediatric ward team or if they had cared for the child previously.
Note that the Borowitz study was in the era before I-PASS became popular and successful as a format for handoffs. The I-PASS format stands for:
I: Illness Severity
P: Patient Summary
A: Action List
S: Situation Awareness and Contingency Planning
S: Synthesis by Receiver
The “S” for “situation awareness and contingency planning” obviously emphasizes the importance of anticipating things that might go wrong or events that might appear and stresses planning for contingencies.
Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our What’s New in the Patient Safety World columns for June 2012 “I-PASS Results and Resources Now Available” and December 2014 “I-PASS Passes the Test” and the I-PASS website. I-PASS is really much more than a handoff format. It really is part of a culture of patient safety.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons
Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update
on Handoffs”
July 12, 2011 “Psst!
Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication
Across Professions”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN
Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More
on Perioperative Handoffs”
June 2012 “I-PASS
Results and Resources Now Available”
August 2012 “New
Joint Commission Tools for Improving Handoffs”
August 2012 “Review
of Postoperative Handoffs”
January 29, 2013 “A
Flurry of Activity on Handoffs”
December 10, 2013 “Better
Handoffs, Better Results”
February 11, 2014 “Another
Perioperative Handoff Tool: SWITCH”
March 2014 “The
“Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The
Handback”
December 2014 “I-PASS
Passes the Test”
January 6, 2015 “Yet
Another Handoff: The Intraoperative Handoff”
March 2017 “Adding
Structure to Multidisciplinary Rounds”
August 22, 2017 “OR
to ICU Handoff Success”
October 2017 “Joint
Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital
Transfers”
References:
Dutra M, Monteiro MV, Ribeiro KB, et al. A Study of Information Loss and Clinical Accuracy to Anticipate Events. Crit Care Med 2018; 46(11): 1717-1721
Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al: Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care 2008; 17: 6-10
https://qualitysafety.bmj.com/content/17/1/6.long
I-PASS Study website.
http://www.ipasshandoffstudy.com/home
Print “PDF
version”
http://www.patientsafetysolutions.com/