Patient Handoff Case Study

Background Information
A literature review of patient handoff, and communication gaps of patient information during intrahospital patient transfers. The communication of complete and accurate patient information can be challenged, because of increasingly fast-paced and complex health care environments. Patient Handoff refers to, the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver. Caregivers include attending physicians, resident physicians, physician assistants, nurse practitioners, registered nurses, and assistant care providers (Patterson, & Wears, 2010). Handoffs serve a critical function in ensuring patient care continuity during
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Arora et al. (2008) mentioned a case study of the implementation of theoretical framework and competency-based approach to night float inpatient general medicine services at the University of Chicago. The proposed conceptual framework defined how handoff affected patients and physicians both. Transition of patient care between two providers serves as “gaps”, which are considered notably vulnerable to errors (Arora et al., 2008). There is an increased risk of adverse events which are preventable when “Cross-covering” physicians’ care for patients. Increased handoff risks for patients which is known as handoff undetermined care. Arora et al. (2008) mentioned cost of co-ordination and agency problems as a key factors to improve handoff. Cost of co-ordination is described as communication failures during medical decision-making, which can be improved by education in handoff communication to providers, for example, using the SBAR technique. Agency problems are described as shift work mentality, lack of responsibility to cross-covered patients, which can be improved by establishing professional responsibility while transferring information about the patient and have the approach that “Every patient is your patient” (Arora et al., …show more content…
Poor communication is identified as a considerable factor to approximately 44000 to 195000 patient deaths. These deaths are because of medical errors. In ED, multiple handoffs happen between nurses, physicians, ancillary staff and other personnel during imaging, testing and admission processes. Around 90% of ED residency directors answered in a survey of no current standardized patient handoff policy. Maughan, Lei & Cydulka (2011) conducted a study to describe ED physician handoff methods and to quantify handoff communication errors. The survey questions were based on handoff literature and senior emergency medicine staff member guidance, 110 handoff sessions enveloping 992 patients were observed. Most errors were due to longer handoff time per patient, and few errors were noted due to use of electronic or written tools. Most laboratory omissions were due to prolonged ED length of stay. Maughan, Lei & Cydulka (2011) concluded clinically pertinent varying data disclosed in ED physician handoff, usually from findings reported in physician documentation. These communication errors were associated with ED length of stay, handoff time per patient and use of support materials (Maughan, Lei & Cydulka,

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