As part of our curriculum- you have navigated through a collection of 10 preventable adverse events related to poor handoff communication. Why did the medical leadership at your institution take the time & effort to have you learn about such a simple task as how to "handoff a patient?"
"Primum non nocere" -- Hippocrates, 4th century B.C.
Hopefully after our curriculum you can begin to appreciate the scope of the handoff problem, as well as it's negative impact on patient care. In 2003 the ACGME implemented work hours restrictions and the 80 hour work week in an effort to decrease fatigue and inattention errors- but they created an unintended consequence of increasing the number of patient handoffs by 40-50%. Given the strong clinical and physiologic evidence that fatigue causes errors- there's no going back. Our healthcare system is full of handoffs and transitions of care- and the problem is here to stay.
How can we tackle such a large and complex problem? It must start with a culture shift. What are the components of creating a "safety culture?"
1) All healthcare personnel must acknowledge the high-risk, error prone nature of the organization where they work
2) The organization must work to create a blame-free environment where individuals are able to report close calls without fear of reprimand
3) There must be collaboration across all parts of the organization to seek solutions and find vulnerabilities
4) There must a willingness of the organization to direct resources when safety concerns and voiced
I hope our handoff project helps to emphasize the need for developing a culture of safety. We cannot allow the culture of low expectations to continue where handoff errors are just accepted as "business as usual." Like other industries which aspire to be high-reliability organizations- the medical profession must develop a preoccupation with failure and be willing to report/analyze our near-misses and direct hits.
Remember the next time you handoff a patient- you are not just passing off a piece of paper. You are transferring RESPONSIBILITY for the patient's overall care. Everyone involved (primary team MDs, RN's, medical and nursing students, patient care techs, pharmacists, SW's, night float team members, consultants, primary care MDs, administrators) is part of ONE team. Each individual must take their part to ensure safety. Collaboration and mutual respect among all members of the team - regardless of hierarchy- is essential to create a culture of safety. Only by changing the culture of healthcare will handoff errors and communication failures be reduced.
