When patients are transferred from one doctor to another, or from an outpatient setting to a hospital or nursing home, there is an increased chance of a serious mishap that can lead to a medical malpractice lawsuit. Who is ultimately found liable for fumbling the patient handoff may be up to a jury to decide years after the event. Plaintiffs' attorneys generally will sue everyone involved in the patients' care – at least initially -- regardless of their degree of accountability, until the facts are clear.
Problems with handoff communication are listed as one of the root causes in up to 70% of adverse sentinel events compiled by the Joint Commission. The potential for something to go wrong -- needed follow-up care that slips through the cracks or vital information that isn't communicated in a timely fashion -- can have life or death impact for patients. It's also a leading driver of malpractice lawsuits against health professionals.
In recent years, handoffs have become more troubling because of the growth in the number of hospitalists -- physicians with no prior relationship to the patient. Just 10 years ago, there were about 3500 physicians describing themselves as hospitalists. Now, there are almost 30,000 practicing in about half of the nation's community hospitals, according to the Society of Hospital Medicine.
The data on lawsuits against hospitalists are sparse because these programs only formally began in 1996, but liability insurers fear that lawsuits due to miscommunication could grow rapidly. That's why they're focusing more attention than ever on studying the anatomy of the handoff and how to thwart mishaps. Handoffs are standard in medicine. Every time a physician goes on vacation or gets sick, it's his or her responsibility to make sure that the covering physician is up to speed on the patients' needs. Every referral to a specialist carries the same responsibility.
As part of its patient safety goals, the Joint Commission on Accreditation of Hospital Organizations (JCAH) in 2006 added a requirement that hospitals seeking accreditation standardize their approaches to handoff communication. The need couldn't be clearer. Numerous studies have shown all sides in the handoff routinely drop the ball and fail to relay timely crucial information to colleagues. What constitutes an effective handoff is rarely taught in medical school. A 2005 study in Academic Medicine found that only 8% of schools talk about handoffs in a formal didactic session.
By definition, the use of a hospitalist causes a change in the flow of continuity of care. Most patients don't know that their primary physicians may not be treating them in the hospital, at least initially. Patients should be told up front that their primary doctors won't be treating them in the hospital. But that isn't always the case. In this setting, if anything goes wrong, patients will be more likely to sue both the hospitalist with whom they had no prior relationship and the primary doctor whom they may feel abandoned them
Every aspect of the transition involved in a referral or handoff has the potential for patient injury and litigation. Did the primary doctor make sure that the hospitalist knows of the patient's allergies? Did the hospitalist speak to the primary when the patient was admitted and discharged? Did the hospitalist convey the need for a follow-up computed tomographic scan in 3 months? Was there a delay in faxing the discharge summary? Does the patient know who he's supposed to contact if complications arise?
A false assumption, lack of documented instructions, and confusion about follow-up care can lead to medical disasters. I recently saw a case involving a man with syncope who insisted on leaving the hospital once the neurologic work-up was complete. His family physician never received the hospital notes, so the patient didn't get a cardiac stress test before his fatal MI (myocardial infarction). For another patient, blood culture results showing that he needed a longer regimen on antibiotics weren't transmitted to the nursing home. The patient developed an infection in his spine, resulting in permanent paraplegia.
The main solution lies in better communication and better policies and procedures. The patient's primary doctor should call the hospitalist directly and clearly state why the patient needs to be admitted, the patient's medications, and any known allergies. There should be a problem list that includes the patient's previous surgeries and hospitalizations. The burden is on the primary physician to send a complete summary of important points and a medication list to the treating physician. That isn't always possible if the patient is admitted at 2 AM but it should be done as soon as possible.
It's best for doctors to speak directly with the other doctor because there will be less chance of things going wrong. At some hospitals, it's a rule for doctors to speak; at others, it's considered OK to leave a message with the staff. However the communication takes place, it should be documented, such as, "left message with Dr. primary's office," "spoke to Mary," "need for follow-up chest x-ray in 3 months." To protect themselves from liability, hospitalists must document that phone call, note who they spoke with, and what was said.
There are plenty of resources to help physicians and hospitals to improve communication about handoffs. One method is as simple as a read-back from your colleague to make sure that you're on the same page. For example, the receiving physician may say, "OK, this is an 84-year-old woman with metastatic liver disease and she's getting a dose of 500 mg of morphine." At this point, the referring physician can correct an error and say, "No, No. It's 50 mg of morphine."
Direct conversation between doctors is superior to relying on electronic forms to get the big picture. It allows each doctor to ask questions and confirm instructions.
Here are some practical suggestions:
- Create a specific standardized checklist for each type of handoff. These checklists can include major diagnosis, recent procedures, medications, names and numbers for all preceding caregivers, who received the patient as a handoff, and all pending labs/images with contact information.
- Keep the communication of the handoff focused on important issues.
- Preferably communicate with the next provider face to face.
- Limit interruptions.
- Avoid diluting the message, and be sure that the people who need to know are in the know.
- Use a common communication style throughout your system.
- Identify potential complications and "if/then" strategies.
- Ask for "read-backs" to confirm that the information is received and understood.