Communicating in the “Gray Zone”: Perceptions about Emergency Physician-hospitalist Handoffs and Patient Safety
ABSTRACT To identify the perceptions of emergency physicians (EPs) and hospitalists regarding interservice handoff communication as patients are transferred from the emergency department to the inpatient setting.
Investigators conducted individual interviews with 12 physicians (six EPs and six hospitalists). Data evaluation consisted of using the steps of constant comparative, thematic analysis.
Physicians perceived handoff communication as a gray zone characterized by ambiguity about patients' conditions and treatment. Two major themes emerged regarding the handoff gray zone. The first theme, poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. Specifically, handoffs consisting of insufficient information, incomplete data, omissions, and faulty information flow exacerbated gray zone problems and may negatively affect patient outcomes. EPs and hospitalists had different expectations about handoffs, and those expectations influenced their interactions in ways that may result in communication breakdowns. The second theme illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Those interviewed talked about the systemic failures that lead to patient boarding and how poor handoffs exacerbated system flaws.
Handoffs between EPs and hospitalists both reflect and contribute to the ambiguity inherent in emergency medicine. Poor handoffs, consisting of faulty communication behaviors and conflicting expectations for information, contribute to patient boarding conditions that can pose safety threats. Pragmatic conclusions are drawn regarding physician-physician communication in patient transfers, and recommendations are offered for medical education.
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ABSTRACT: Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format. A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns. Use of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions. The HAND-IT's body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.Journal of critical care 11/2013; 29(2). DOI:10.1016/j.jcrc.2013.11.014 · 2.19 Impact Factor
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ABSTRACT: Die Messung und Evaluation von Sicherheitskultur in der internationalen Versorgungsforschung gewann in den vergangenen Jahren zunehmend an Bedeutung. Ziel der vorliegenden Arbeit ist es, ein Instrument zur quantitativen Messung der Sicherheitskultur im Krankenhaus psychometrisch zu evaluieren. Dies wird in der Publikation dieser kumulativen Dissertationsschrift beschrieben. Im Vorfeld hierzu wird im zweiten Kapitel der Begriff der Sicherheitskultur auf Grundlage von theoretischen Auseinandersetzungen hergeleitet und vom Begriff des Sicherheitsklimas abgegrenzt. Im dritten Kapitel werden die gemeinsamen Aspekte dieser beiden Konzepte herausgearbeitet und in 15 wesentlichen Dimensionen zur quantitativen Erfassung von Sicherheitskultur zusammengefasst. Auf Grundlage einer systematischen Literaturrecherche wird im vierten Kapitel ein Überblick über die Instrumente zur quantitativen Messung von Sicherheitskultur geschaffen. Hauptbestandteil dieser Arbeit ist der im fünften Kapitel vorgestellte Artikel zur psychometrischen Evaluation des Hospital Survey on Patient Safety Culture für das Krankenhausmanagement (HSOPS_M). In der vorliegenden Publikation wurde geprüft, ob der für eine Befragung von ärztlichen Direktoren adaptierte Hospital Survey on Patient Safety Culture für das Krankenhausmanagement (HSOPS_M) vergleichbare psychometrische Eigenschaften aufweist wie der für eine Befragung von Mitarbeitern konzipierte HSOPS. Die Ergebnisse sprechen für angemessene psychometrische Eigenschaften des HSOPS_M. Das Instrument ist für eine quantitative Erfassung der Sicherheitskultur aus Perspektive des Krankenhausmanagements geeignet. Der HSOPS_M kann national aber auch international als Benchmark-Instrument dienen.06/2012, Degree: Dr rer med, Supervisor: Holger Pfaff
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ABSTRACT: "The whole system is inherently dangerous. Um, but that is the way it always has been. And I think that it should get better, but it would be hard to make it better" [Luke - F2 doctor] As a result of changes in working patterns, handovers between doctors have recently become more frequent and more important for patient safety. In the UK there is wide variability between hospitals and departments as to how handovers take place, with no agreed structure. In this study, 19 doctors from three hospitals took part in qualitative, in-depth, semi-structured interviews to explore the problems encountered in handover and their consequences, as well as recommendations for improvement. Thematic analysis revealed a need for regular, well-attended handover meetings with clear, formal structure and a nominated lead. There was specific, vital content which needed to be communicated, as well as a balanced level of background detail. Participants had all experienced adverse incidents due to poor or missed handover while many felt a good system improved working relationships both within and between teams. Recommendations are made involving training, suggested format and staff representation in handover.