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Study offers fixes to miscommunication in patient transfers

- By Sara Wykes

Stanford Hospital & Clinics description of photo

Patrick Gibbons, Nancy Szaflarski and Christine Thompson, discuss the Hand-off Communication Project in one of the hospital’s intermediate intensive care units.

Each time a patient moves from one area of a hospital to another, or leaves the hospital to go to another facility, critical medical information about the case should be transferred from one medical team to the next, but that exchange poses serious challenges.

“Every patient hand-off provides many opportunities for error,” said Mark Chassin, MD, president of The Joint Commission, the accrediting organization for U.S. hospitals. Studies estimate that as many as 80 percent of preventable errors begin with poor communication between caregivers.

To address these issues, The Joint Commission last year enlisted 10 health-care organizations, including Stanford Hospital & Clinics, to look closely at why patients’ medical information isn’t adequately shared between health-care professionals. On Oct. 21, the project presented its answers — and effective solutions.

As a group, the hospitals had a 37 percent defect rate in patient-transfer communications at the start of the study, but in the course of the year they were able to cut that by half, said Chassin.

The reasons for failed hand-offs were many, Chassin said, but common themes did emerge regardless of the type of hospital: Lack of teamwork and respect between senders and receivers, and different expectations between senders and receivers about what information should be conveyed were two of the most frequently found. Sometimes, Chassin said, the failures were caused by distractions, competing priorities or lack of a standardized method for the communication.

SHC, as part of the effort, forged ahead with a pilot hand-off project, focusing on transfers of patients between two intensive care units and two intermediate intensive care units.

“Time and time again, we’ve found problems with hand-offs at the heart of safety and quality problems at our institution,” said Kevin Tabb, MD, SHC’s chief medical officer. Working with the study group, he said, “has been particularly valuable to make sure we learn from each other’s successes and failures. There are a fair number of different types of hospitals represented here, yet everybody is facing similar issues.”

Added Patrick Gibbons, MD, physician co-leader of Stanford’s Hand-off Communication Project: “Our consumers assume that when they move from one place to another that doctors get together and discuss them. The reality is I’m not sure we’re achieving the standards patients expect of us. Our job is to make our practices achieve that.”

The pilot program has been successful in improving hand-offs, and Gibbons believes that the very first step in the change process was one of the most important. “We asked physicians what the problems were and how we could improve the hand-off,” he said, “and the solutions came from them.”

Their investment in the process made sense. Residents, for instance, live “in lunar cycles,” Gibbons said. “One month you’re the sender, the next you’re the receiver.” That means that they could appreciate the challenges on both ends of the transfer and have insights about the needs of both sides.

One crucial issue was resolving the difference in expectations to create effective hand-off standards. “Senders thought receivers could retrieve needed information in Epic [SHC’s electronic health record system]," explained the project’s nursing and outcomes co-leader Nancy Szaflarski, RN, PhD, SHC’s program director-quality outcomes. “Receivers, on the other hand, expected a concise summary since they didn’t have time to read across the entire medical record. The key to leveling expectations was standardizing what information needed to be shared and implementing guidelines for verbal hand-off.”

Overall the report from The Joint Commission identified such solutions as standardizing critical content, including details of a patient’s medical history; identifying new and existing technologies to assist in the hand-off; and allowing the opportunity for sender and receiver to ask questions.

Although The Joint Commission had already created a set of standards for hand-off communication, it felt the problem was still so serious that a second effort was justified. “We as a commission have focused on hand-offs as a known problem,” Chassin said, “and each of the participating hospitals was already devoting significant resources to try to avoid failures. That’s why we are working to come up with better and new ways to systematically handle them.”

At SHC, clinical nurse specialist Christine Thompson, RN, MSN, and Stephanie Moore, patient-care service program manager, will lead a task force to take the changes introduced in the pilot program for the ICUs and intermediate intensive care units and integrate them into all SHC inpatient units.

Chassin said The Joint Commission would like to see hospitals achieve a 90 percent success rate. But based on an estimated 4,000 hand-offs a day in a teaching hospital, even that success rate would still mean 400 failures a day. “The consequences of these kinds of miscommunications cause serious problems,” he said.

As the participating hospitals expand their hand-off improvement program and validate the set of tools they’ve used, that information will become part of solutions available at The Joint Commission’s Center for Transforming Health-care website. The solutions will also include ways to accurately measure performance and identify barriers to performance.

Other health-care organizations in the study were: Fairview Health Services, Minneapolis; Intermountain Healthcare LDS Hospital, Salt Lake City; Johns Hopkins Hospital, Baltimore; Kaiser Permanente Sunnyside Medical Center, Clackamas, Ore.; Exempla Lutheran Medical Center, Wheat Ridge, Colo.; Mayo Clinic Saint Mary’s Hospital, Rochester, Minn.; New York-Presbyterian Hospital, New York; North Shore-LIJ Health System Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, N.Y.; and Partners HealthCare, Massachusetts General Hospital, Boston.

Sara Wykes is a writer in Stanford Hospital’s communications office.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford School of Medicine, Stanford Health Care, and Stanford Children's Health. For more information, please visit the Office of Communications website at

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