New methods are in the works at hospitals to ensure consistent care for patients… (Thomas Barwick, Getty Images )
Consider the following story, from a doctor during his training: During a night on call, a patient he was "cross covering" — caring for during the night shift — went into cardiac and respiratory arrest. Dutifully, the resident and his team began to resuscitate the patient.
They performed CPR for well over a minute. Then, suddenly, they stopped — and not because the patient was beyond saving. Another team member had reviewed the patient's chart and learned he was not a "full code." The patient, in other words, had requested as part of his treatment plan that he not be revived should his body fail. Trying to save him had been wrong.
This mess-up — like many other errors in medicine — happened because of a botched handoff, the process by which a physician going off duty transfers responsibility of a patient to another doctor. In this case, the doctor going off duty had failed to communicate the patient's code status to the resident taking over his care.
Handoffs are the glue that holds together a patient's care in the hospital. Yet traditionally they have been a disorganized — even sloppy — process. During my residency, we used paper and pencil to keep track of patients and transfer their care to others. We kept these pieces of paper folded in our pockets and constantly updated them by erasing and rewriting on them.
Over the course of a day and a night on call, that pristine piece of paper got tattered and torn, confused with scribbles, eraser marks and shorthand made by many doctors. Somewhere on that paper was the right information, but it wasn't always easy to find.
It was probably more luck than smarts that saved me from making any major mistakes through my own imperfect handoffs. Statistics show that some 80% of adverse events in hospitals involve communication problems between healthcare professionals, often in the form of a fumbled handoff. A review of surgery malpractice cases from 1991 to 2000 reported that inadequate information-sharing among team members was the primary trigger for lawsuits.
Other studies show that such lapses in communication lead to problems even when patients do not get injured or die and doctors do not get sued. Fumbled handoffs can lead to redundant tests, prolonged hospitalizations or readmissions after discharge, all of which lower the quality of care for patients and drive up healthcare costs.
To learn more about the issue, I talked to Dr. Vineet Arora, assistant director of the Internal Medicine Program at the University of Chicago Pritzker School of Medicine, who has made understanding and improving handoffs the focus of her career. She told me that handoffs have come under fresh scrutiny because of the way medicine has changed over the last decade.
There was a time in American medicine when each person had a doctor who followed him or her whether well or sick, in or out of the hospital. These days, you may see your family doctor when you are well, but if you are sick and need to be hospitalized, an expert in inpatient medicine — a hospitalist — will assume your care. And since no single hospitalist can be present around the clock, patients end up receiving care from several different ones, in shifts.
"We've traded familiarity and continuity for safety," Arora told me.
The trend toward more shift changes — so that residents don't have to work as many hours without a break, a safety move — has led to far more handoffs and, ironically, to a new set of dangers.
Experts like Arora cite a host of reasons why handoffs fail.
Some seem trivial — such as the fact that one doctor's shorthand can mean something entirely different to another. The notation "MI," for example, may mean "myocardial infarction" (heart attack in plain English) to one physician and "mitral insufficiency" (a condition affecting one of the valves of the heart) to another.
Frequent interruptions during the handoff process are another problem — an extremely common one. In the middle of a discussion, a doctor's beeper may go off, or a nurse or other staff member will come over needing something right away, breaking the rhythm of discussion and the doctor's concentration.
Hospitalists also care for large numbers of patients, many of whom have multiple, chronic, complex medical problems such as cancer, heart disease or dementia. With such patients come many drugs and much data to track — and more opportunities for a mix-up. A "typical" primary-care doctor may review up to 800 lab results, 40 radiology reports and 12 pathology reports per week. Those numbers are undoubtedly far higher for hospitalists.
There's a cultural issue as well. Many doctors seem to view handoffs as an annoyance, even with disdain. Often, the question doctors are asking when they hand patients off isn't "How do I get this right each time so that my patients stay safe?" but "How do I get this done so I can get out of here fast?"