Grand Rounds Report: The Importance of Effective Patient Care Hand-offs

by Academy of Clinical Excellence on October 26, 2010

A few weeks ago, at medical grand rounds, Dr. Jeffrey C. Trost, presented our equivalent of “the morbidity and mortality conference” entitled the "Patient Safety and Quality Conference".Dr. Trost presented the case of an older gentleman who was sent to our emergency department from a nursing home with a thigh hematoma and a supratherapeutic INR (he was taking Warfarin for atrial fibrillation). He was admitted to the medicine ward, and was subsequently taken to the operating room. After the operation, the patient was transferred to the medical intensive care unit (ICU) for postoperative care and monitoring.

Over the course of a limited number of hours, the patient’s care and supervision was transferred from providers at the nursing home, to emergency medical technicians, to the emergency room, to the medical ward team, to the surgical team, and then finally to the ICU.

Dr. Trost highlighted the importance of effective ‘information handoffs’ required in order to deliver high-quality care to our patients. He presented a model for us to consider when the stakes are high and time is short – the example from Dr. Ken Catchpole’s article “Patient handovers within the hospital: translating knowledge from motor racing to healthcare” were presented.

The audience was also reminded of how horrible errors with unfortunate outcomes can occur when inadequate attention is directed toward the hand-off. In one of Dr. Pauline Chen’s NYT articles, she tells the story of one surgeon scrubbing out after painstakingly resecting a tumor from a young boy’s face while carefully protecting a nerve only to have the next surgeon (scrubbing in to finish the case) snip the nerve.

Now more than ever, medicine is a collaborative team effort. We must all learn from best practices and remember to handoff patient care in the way that we would want it done if the patient was our child or parent.

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