No matter how swift the runners, a relay race is lost if they don’t pass the baton properly. A new Yale study finds that patient care is a baton at increasing risk of being dropped because too many internal medicine residency programs lack systems for transmitting patient information from shift to shift.
Communication failure is one of the chief causes of medical errors, studies have found, and the transfer of care is a weak link in the chain. But the Yale study, published in the Archives of Internal Medicine in June, finds that many hospitals lack an established protocol for passing on patient information, even though transfers, also known as sign-outs, are becoming more common as residents work fewer hours.
“Communication is not something that the layman thinks is a problem,” said Leora I. Horwitz, M.D., a post-doctoral fellow in internal medicine and the study’s lead author. However, patients are now under the care of more doctors, due to limits on residents’ workweeks. Transfers “happen routinely and have the potential for catastrophe,” she said.
Hospitals should have a standardized system each time a doctor hands off a patient to another doctor, Horwitz said.
Horwitz’s team investigated the sign-out practices at 202 internal medicine residency programs in the United States and the impact of the reduced workweek on patient transfer protocols. Patient transfers, they found, rose 11 percent—to an average of twice daily in a four-day hospital stay—since the regulations took effect in 2003.
The procedures for those handoffs varied widely, though. Fifty-five percent of the programs didn’t require doctors to pass on key patient information in both oral and written form, which Horwitz said would curtail the risk for errors. In six of 10 programs, nurses were not informed that a transfer had occurred, and in many programs no workshops or lectures on sign-out skills were offered. In 34 percent of the cases, the handoff was left to interns alone. And fewer than a fifth of the programs used a Web-based program, or forwarded pager messages in the transfer process.
“If you’re the primary doctor, you’re much less likely to make a preventable error than if you’re covering that person just for a day and you don’t know that [patient] well,” Horwitz said. An oral transfer allows the new doctor to ask questions or give “readback”—like a pilot would give to an air traffic controller. Written information can be referred to later if needed.
The sign-out can differ from hospital to hospital, but it needs to be consistent within the health care organization, said Paul M. Schyve, M.D., senior vice president of the Joint Commission on Accreditation of Healthcare Organizations, which made sign-outs one of its chief patient safety goals for 2006. “A standardized approach makes it easy for people to ask and respond to questions,” he said.
The survey didn’t examine whether the various approaches to sign-outs actually prevent medical errors, especially in light of the shorter workweek. “There’s a lot of anxiety around work-hour limitations in terms of whether they increase discontinuity enough that it overwhelms the benefits of physicians being rested,” Horwitz said. Future studies will decide “whether that’s clinically significant or not.”