AAOS Now

Published 6/1/2016
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Andrew Grose, MD

Optimizing Patient Safety while Transferring Information

Checklists can help providers properly manage patient handoffs
Patient safety relies, to a significant extent, on healthcare providers' ability to exchange critical information about patients effectively and to properly manage handoffs from one provider to another. Fortunately, a few simple rules for exchanging important patient information have been shown to dramatically increase the likelihood of success. The following rules apply regardless of the situation:

  • An individual cannot process information while his or her attention is directed elsewhere. This leads to the first rule of information exchange—no distractions. The discussion should be in a "sterile" environment (ie, with no distractions or attempts to accomplish other tasks).
  • All participants should know one another's names and how to contact one another in the future, if needed.
  • The exchange should be standardized. This organizes the sender's thoughts and helps the receiver recognize discrepant or absent information from the expected pattern.
  • All information should be acknowledged by the receiver. This means the receiver should repeat the information back to the sender to ensure it was heard and understood correctly. It is the sender's responsibility to ensure this acknowledgment is made. Passing data on in written form is helpful as well.
  • There must be an opportunity for questions at the end of the exchange. This is best accomplished as a prompt from the sender such as, "What questions do you have for me?"

As humans, we have an overwhelming tendency to abbreviate any process by skipping items. This can be understood as one of many efficiency-thoroughness tradeoffs we make on a daily basis.

With respect to communication, however, shifting from thoroughness toward efficiency is an easy trap. We assume that things that are already simple to us require little explanation. We can often feel completely justified, therefore, in sometimes skimping on process during certain exchanges.

Using checklists
For this reason, such exchanges are best governed by a checklist. Ample evidence exists that checklists help remind the sender to cover all the basic steps. Under best practices, every hospital and/or department would have a standardized process to which all providers adhere.

For transitions of care, using a guided format such as a 'read-and-do' checklist is probably best. One example is SBAR (Situation, Background, Assessment, Recommendations). SBAR is particularly well-suited for providing information updates or quickly reporting on a new patient to a colleague.

I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Syntheses by receiver) (Fig. 1) was specifically developed from a longer TeamSTEPPS ® version for use in handoffs of complex patients.

It is important to note the elements that are absent from these options. For example, neither requires introductions or a prompt for questions, although I-PASS does require some form of acknowledgment that could include questions.

Ultimately, what is important is that the first principles of effective communication are understood and followed by all involved. In this way, communication can be viewed in the same light as knee replacement or fracture care, in that performing either of these surgeries without paying attention to first principles can be expected to result in a high rate of failure. The reason communication is critical in health care is that we, as physicians, perform many more communication procedures daily than we do surgeries.

As long as we do not consider communication a procedure with essential steps to get right and do not always take the lead to ensure these practices are done well, we will continue to see both communication and leadership as major causes of sentinel events and major medical errors. Just as we take responsibility for surgical care, we must be responsible for effective communications with our patients and our colleagues.

Andrew Grose, MD, is a member of the Patient Safety Committee. He can be reached at docgrose@gmail.com

Editor's Note: This article, the second in a two-part series on patient handoffs and sign-outs, reviews the concepts and supportive data of effective information transfer methods currently considered best practices.

References:

  1. Haig KM, Sutton S, Whittington J. (2006). SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32(3):167–175.
  2. Hollnagel E. The ETTO Principle: Efficiency-Thoroughness Trade-off. Farnham, UK, Ashgate, 2009.
  3. Merritt A, Klinect J. Defensive Driving for Pilots: An introduction to Threat and Error Management. Austin, The LOSA Collaborative, 2006
  4. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC, I-PASS Study Group. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics, 2012;129(2):201–204. doi: 10.1542/peds.2011-2966. Epub 2012 Jan 9.