Improving the Patient Handoff Process in the Intensive Care Unit: Keys to Reducing Errors and Improving Outcomes

被引:39
作者
Colvin, Mai O. [1 ]
Eisen, Lewis A. [2 ]
Gong, Michelle Ng [3 ]
机构
[1] Albert Einstein Coll Med, Dept Internal Med, Montefiore Med Ctr, Bronx, NY 10467 USA
[2] Albert Einstein Coll Med, Div Crit Care Med, Dept Med, Montefiore Med Ctr, Bronx, NY 10467 USA
[3] Albert Einstein Coll Med, Div Epidemiol & Populat Hlth, Dept Med, Montefiore Med Ctr, Bronx, NY 10467 USA
关键词
handoff; handover; critical care; patient safety; communication; continuity of care; medical error; quality improvement; CLOSED MALPRACTICE CLAIMS; SIGN-OUT; MEDICAL ERRORS; WORK HOURS; COMMUNICATION FAILURES; HEALTH-CARE; QUALITY; PHYSICIAN; IMPLEMENTATION; IMPROVEMENT;
D O I
10.1055/s-0035-1570351
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Patient handoffs are highly variable and error prone. They have been recognized as a major health care challenge. Patients in the intensive care unit are particularly vulnerable due to their complex clinical history and the critical nature of their condition. Given a general movement from traditional long call to shift schedules, the number of patient handoffs will likely continue to increase. Optimization of the handoff process has become even more critical to ensure patient safety. In this review, we reflect on the importance of the handoff process, review common errors, identify barriers and challenges, and propose different methods to improving the handoff process. The purpose of this article is to examine the overall scope of the problem; provide the most up-to-date evidence on the handoff process; and identify ways to perform handoffs in an accurate, safe, and efficient manner to provide high-quality patient care. The direction of future research is also proposed.
引用
收藏
页码:96 / 106
页数:11
相关论文
共 76 条
[61]   Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room [J].
Smith, A. F. ;
Pope, C. ;
Goodwin, D. ;
Mort, M. .
BRITISH JOURNAL OF ANAESTHESIA, 2008, 101 (03) :332-337
[62]   Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs [J].
Solet, DJ ;
Norvell, JM ;
Rutan, GH ;
Frankel, RM .
ACADEMIC MEDICINE, 2005, 80 (12) :1094-1099
[63]   Changes in Medical Errors after Implementation of a Handoff Program [J].
Starmer, A. J. ;
Spector, N. D. ;
Srivastava, R. ;
West, D. C. ;
Rosenbluth, G. ;
Allen, A. D. ;
Noble, E. L. ;
Tse, L. L. ;
Dalal, A. K. ;
Keohane, C. A. ;
Lipsitz, S. R. ;
Rothschild, J. M. ;
Wien, M. F. ;
Yoon, C. S. ;
Zigmont, K. R. ;
Wilson, K. M. ;
O'Toole, J. K. ;
Solan, L. G. ;
Aylor, M. ;
Bismilla, Z. ;
Coffey, M. ;
Mahant, S. ;
Blankenburg, R. L. ;
Destino, L. A. ;
Everhart, J. L. ;
Patel, S. J. ;
Bale, J. F., Jr. ;
Spackman, J. B. ;
Stevenson, A. T. ;
Calaman, S. ;
Cole, F. S. ;
Balmer, D. F. ;
Hepps, J. H. ;
Lopreiato, J. O. ;
Yu, C. E. ;
Sectish, T. C. ;
Landrigan, C. P. .
NEW ENGLAND JOURNAL OF MEDICINE, 2014, 371 (19) :1803-1812
[64]   Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle [J].
Starmer, Amy J. ;
Sectish, Theodore C. ;
Simon, Dennis W. ;
Keohane, Carol ;
McSweeney, Maireade E. ;
Chung, Erica Y. ;
Yoon, Catherine S. ;
Lipsitz, Stuart R. ;
Wassner, Ari J. ;
Harper, Marvin B. ;
Landrigan, Christopher P. .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2013, 310 (21) :2262-2270
[65]   I-PASS, a Mnemonic to Standardize Verbal Handoffs [J].
Starmer, Amy J. ;
Spector, Nancy D. ;
Srivastava, Rajendu ;
Allen, April D. ;
Landrigan, Christopher P. ;
Sectish, Theodore C. .
PEDIATRICS, 2012, 129 (02) :201-204
[66]   Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation [J].
Steinberger, Dina. M. ;
Douglas, Stephen V. ;
Kirschbaum, Mark S. .
PROGRESS IN TRANSPLANTATION, 2009, 19 (03) :208-214
[67]   Handoffs in care - Can we make them safer? [J].
Streitenberger, Kim ;
Breen-Reid, Karen ;
Harris, Cheryl .
PEDIATRIC CLINICS OF NORTH AMERICA, 2006, 53 (06) :1185-+
[68]   Communication failures: An insidious contributor to medical mishaps [J].
Sutcliffe, KM ;
Lewton, E ;
Rosenthal, MM .
ACADEMIC MEDICINE, 2004, 79 (02) :186-194
[69]   A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room [J].
Thakore, S ;
Morrison, W .
EMERGENCY MEDICINE JOURNAL, 2001, 18 (04) :293-296
[70]   That's all I got handed over - Missed opportunities and opportunity for near misses in Wales [J].
Tokode, M ;
Barthelmes, L ;
O'Riordan, B .
BMJ-BRITISH MEDICAL JOURNAL, 2006, 332 (7541) :610-610