“Breakdowns in communication” were cited as the second leading cause of medical errors in orthopaedic practice, according to a 2005 survey of AAOS members conducted by the Patient Safety Committee.¹ These communication lapses accounted for 26 percent of all reported errors.

Obstacles to good communication involve both individual and systemic problems. Orthopaedic surgeons can decrease overall medical errors—and improve the quality of patient care—by identifying where communication breakdowns occur most often and implementing systems to minimize those errors. Transferring patient care to another physician, for example, presents multiple opportunities for miscommunication and, thus, is an excellent place to start such an analysis.

Patient hand-offs
The resident 80-hour work week rule has increased the number of care transitions per patient, thus increasing the opportunity for errors in communication.² System problems include the lack of a formal sign-out or “hand-off” procedure, which may lead to errors if important information is omitted or is communicated in a confusing manner.² Individual factors, such as resistance to change, can create communication barriers as well. If a surgeon is unwilling to relinquish work responsibility to others, or feels uncomfortable handing off patients to higher-ranking physicians, communication errors can result.³

When addressing communication system errors—particularly during patient care transitions—both surgeon-to-surgeon communication and communication between surgeons and ancillary staff such as nurses, nurse practitioners, and physician assistants must be considered. Lack of communication between surgeons and nursing staff at sign-out provides another opportunity for missed information.

Tips for improving transitions of care
The following specific factors are identified with improved communication during transitions of care:⁴

• Providing a printed, up-to-date sign-out form at the time of hand-off
• Conducting face-to-face hand-off at multiple levels—horizontally, if possible (such as nurse-to-nurse or resident-to-resident)
• Signing out as a team, when possible
• Discussing all of the patients on the form
• Providing a separate “to do” list
• Recording overnight events on the sign-out form for delivery to the incoming team the following day

List management can be improved by implementing the following recommendations:

• Loosen restrictions on who may revise the information
• Print out patient data rather than hand-copying it
• Allow access to the data from anywhere, including from home via computerized systems⁴

Some institutions have successfully implemented some of these key factors by establishing various new practices, including the use of a formal morning report. This provides the opportunity for a team sign-out approach, as well as an educational opportunity for staff and residents.⁵ Encouraging discussion and attempting to change expectations of junior team members can also lead to more open communication and better patient care.³

Some institutions have implemented computerized sign-out systems to standardize data and to save time for those involved.⁴ These systems can be accessed by all team members, including surgeons, nurses, and allied health staff. Errors are reduced, in part, because patient data is obtained directly from hospital computer systems, thus eliminating transcription errors.⁶ The computerized systems can be further enhanced by the use of personal digital assistants (PDAs),⁷ which not only allow providers more time to complete other activities, but also reduce stress and decrease the potential for causing errors.

Our experience
Our experience on the orthopaedic service at Hahnemann University Hospital in Philadelphia illustrates some of the obstacles to communication, as well as some of the ways we resolved these problems.

First, our sign-out list is maintained in a word processing file on a single computer that is accessible to all members of the orthopaedic team. Although our system does not achieve the goal of being accessed from anywhere in the hospital, it is both low-cost and easily implemented. This system still relies on hand-copying data onto a form, but it provides everyone with a printed list with up-to-date patient data at the time of sign-out. Maintaining this list on a single computer allows all of the information to be collected in one location, which minimizes the potential for duplicate lists with erroneous information.

Another way we minimize problems is through a formal team sign-out in the morning and evening, as transitions occur. X-rays from new consultations are reviewed by the whole team, which allows for education of more junior team members and provides an opportunity for contributions to patient care from all team members. We are still attempting to develop a reliable means of communicating with nursing staff, beginning with an informal sign-out in the evening between the resident on call and the orthopaedic ward nurses.

Although no system is perfect, improving hand-off communication is possible and should be attempted so that the overall rate of medical errors that hurt our patients is reduced.

Harold W. Rees, MD, is a PGY5 orthopaedic resident at Drexel University College of Medicine in Philadelphia. orman A. Johanson, MD, is chairman of the department of orthopaedic surgery, Drexel University College of Medicine, and a member of the AAOS Patient Safety Committee and the AAOS Evidence- Based Practice Committee.

Additional References

1. Wong, DA, AAOS Member Patient Safety Survey: A First Look. AAOS Bulletin, August 2006.
2. Horwitz, LI, Krumholz, SM, Green, ML, Huot, SJ, Transfers of Patient Care Between House Staff on Internal Medicine Wards: A National Survey. Arch Int Med 2006;166:1173-1177.
3. Kellogg, KC, Breen, E, Ferzoco, SJ, Zinner, MJ, Ashley, SW, Resistance to Change in Surgical Residency: An Ethnographic Study of Work Hours Reform. J Am Coll Surg 2006;202:630-636.
4. VanEaton, EG, Horvath, KD, Lober, WB, Pellegrini, CA, Organizing the Transfer of Patient Care Information: The Development of a Computerized Resident Sign-Out System. Surgery 2004;136:5-13.
5. Stiles, BM, Reece, TB, Hedrick, TL, Garwood, RA, Hughes, MG, Dubose, JJ, Adams, RB, Schirmer, BD, Sanfey, HA, Sawyer, RG, General Surgery Morning Report: A Competency-Based Conference that Enhances Patient Care and Resident Education. Curr Surg 2006 Nov-Dec;63(6):385-390.
6. Sidlow, R, Katz-Sidlow, RJ, Using a Computerized Sign-Out System to Improve Physician-Nurse Communication. Jt Comm J Qual Patient Saf 2006 Jan;32(1):32-36.
7. Joy, S, Benrubi, G, Personal Digital Assistance Use in Florida Obstetrics and Gynecology Residency Programs. South Med J 2004 May;97(5):430-433.