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In Practice

Doctors could learn something about medical handoffs from the Navy

Mistakes commonly occur when a doctor goes off duty and transfers responsibility of a patient to another doctor. Handoffs are being studied and revamped to ensure continuity and consistency of communication and care.

April 18, 2011|By Rahul Parikh, Special to the Los Angeles Times

The reasons go on and on, but the tough question is how to make handoffs safe and effective. In their search for solutions, many patient-safety experts are looking for answers outside of healthcare.

At Kaiser Permanente, where I practice, Doug Bonacum, vice president of Safety Management, is tasked with making handoffs work. He's not a doctor himself — he's a nuclear engineer and former Navy submariner. He is trying to show that the techniques he learned in the military to communicate are the exact same ones doctors need to use during handoffs.

"When I set foot on a nuclear submarine fresh out of the Naval Academy, the very first thing I had to prove was that I could use the phone," he recalls. "That really surprised me, given that we had nuclear generators and weapons on this ship. But I wasn't allowed to do anything more until I had shown that I could receive, and read back, an order. If I couldn't, the officer on the line would say 'Wrong' and 'Repeat again' until I got it right."

Bonacum shared example after example of how care of the submarine was handed off during a change of shift. "I would sign out the issues and events that happened on my watch the same way each day," he says. "Anybody who assumed my post would do it the exact same way to their relief as well. In medicine, if I follow three different doctors around on three different days, I'll see three different ways of signing out patients."

Doctors are also learning from aviation, where critical processes are handled using checklists. Checklists have already improved patient safety in intensive care units and operating rooms. Some centers have created handoff checklists too to ensure crucial items (such as a patient's code status) are never missed.

But there's more to be learned from the field. Another aviation technique — the "sterile cockpit" — requires that pilots refrain from nonessential activities during certain points during flight. It's designed to limit interruptions when the crew talks about critical issues related to the flight. In medicine, that would mean setting aside a quiet place for handoffs that are buffered from beepers, phones and other distractions.

We doctors could also learn a lot by just looking over our shoulder at nurses. Anybody trying to talk to a nurse during a shift change, be it a doctor, a family member or a patient, gets mildly reprimanded. Nurses are simply off-limits while they're handing off patients. At Kaiser, nurses have adopted another innovative technique: signing off at a patient's bedside so that patients and family members will hear the plan and have an opportunity to ask questions or correct something if it does not sound right.

Bonacum and Arora say they see generational differences in doctors' willingness to embrace better handoff techniques, which is a hopeful sign. Residents, who are increasingly required to have formal training in handoffs, are fast adopting new techniques. They seem to have the perspective that teams of people working together keep patients safe.

Yet for more seasoned doctors, there's inertia. Many consider advice or a mandate to do things one way every time — be it a handoff or something else, like using a checklist — as an insult to their intelligence and authority.

The sad thing is, they often feel a deep sense of personal responsibility for their patients, which leads them to blame themselves when things go wrong. Yet the very systems they bristle against could well prevent those errors to begin with.

Parikh is a physician and writer in the San Francisco Bay Area. He writes PopRx, a weekly column about medicine and culture, for

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