The competing demands of mastering minutiae and working expeditiously create tension for many healthcare providers. Efforts to satisfy both these goals often involve negotiating "efficiency-thoroughness trade-offs," a normal process wherein providers strike a balance between productivity and safety. This is particularly evident when providing patient information during transitions of care.
Data are often lost or degraded when information is transferred and, paradoxically, attempts to maximize thoroughness often only worsen the situation. Recognition of this, therefore, needs to be an integral part of care transition discussions. Most importantly, how to best manage conflicting goals to minimize the potential for patient harm must be addressed.
This article, the first of a two-part series on patient handoffs and sign-outs, explores the breakdowns in information transfer that can occur during a patient's transition of care.
In a hypothetical situation, a patient presents to the emergency department (ED) at 4:00 a.m. with a distal femur fracture caused by a simple fall from standing. The fracture is associated with a 4-mm to 5-mm clean wound at the anterior knee. Because the patient has complex medical problems (body mass index greater than 70, noninsulin-dependent diabetes mellitus, hypertension, and is on immunosuppressives for rheumatoid arthritis), the ED attending physician consults the medicine hospitalist and the patient is admitted to the medical service.
The patient is also assessed separately by the physician's assistant (PA) working for the on-call orthopaedist. Convinced that the fracture is open, the PA alerts the attending orthopaedic surgeon of the open fracture and recommends a plan for tetanus prophylaxis, antibiotics, and rapid surgical management. The attending orthopaedist agrees, so the orthopaedic PA also calls the admitting hospitalist and explains that the patient "needs to go to the operating room (OR) for an urgent repair today." No conversation takes place between the orthopaedic service and the ED physician.
While the orthopaedic team arranges for the case to go to the OR, the overnight hospitalist hands off to the oncoming hospitalist, explaining the patient's medical issues and the need for urgent fracture repair. The new hospitalist considers the patient at high risk for complications and therefore plans a 2-day stress-test; the hospitalist also orders heparin and a diet for the patient. As a result, the patient receives 5,000 units of heparin as well as breakfast early in the morning, just prior to a planned surgical treatment of the open distal femur fracture.
Unfortunately, outcomes such as these are frighteningly common. Hindsight, however, is of little use when determining what to do in real time. Rather than attempt to point to what people should have done, it is more useful to consider the world from their point of view. As providers working in vivo, we need to keep in mind what information will be required by others and when. Often the "when" is dictated to us by a formal transition of care, but that is not always the case.
Enhancing information exchange
Diverse teams with varying expertise can result in better patient care, but also bring increasingly narrow viewpoints that can pursue divergent paths with conflicting goals. As practitioners working at the sharp end of the stick, our role is to manage those conflicts. "Threat Management & Task Adaptation" is an excellent model of how this can be accomplished. This model assumes that some tasks involve events—or threats—outside the control of the team, yet team management is required for these tasks to be successfully completed. For example, the patient described above presented to the ED with threats of open fracture, morbid obesity, medical comorbidities resulting in immunosuppression, and cardiovascular risk—all of which needed to be managed. In addition, each team involved in a patient's care follows its own pathway, creating another category of threats.
Effective communication between providers is not only a safety buffer, but also a way to minimize redundant work (where possible) and maintain balance between goal conflicts. Unfortunately, effective communication—which needs to be precise, concise, and timely—can be hindered by significant barriers. These include hierarchy, jargon, turf or silo mentalities, fear, distractions, and assumptions. As a result, some information will undoubtedly be lost in transfer. Adhering to the following standard requirements for exchanging information between providers can help minimize this risk:
- The information exchange should occur in a "sterile" environment, meaning a place without distractions.
- The information should be delivered in a standardized fashion.
- Both providers should know each other's names and contact information.
- The receiver should repeat all information back to the sender to ensure accuracy.
- The sender should ask the receiver if he or she has any questions.
Andrew W. Grose, MD, is a member of the AAOS Patient Safety Committee.
- Hollnagel E: The ETTO Principle: Efficiency-Thoroughness Trade-off. Surrey, England, Ashgate, 2009.
- Merritt A, Klinect J: Defensive Driving for Pilots: An Introduction to Threat and Error Management. Austin, The LOSA Collaborative, 2006.