Communicating in the “Gray Zone”: Perceptions about Emergency Physician-hospitalist Handoffs and Patient Safety

School of Communication, Western Michigan University, Kalamazoo, MI, USA.
Academic Emergency Medicine (Impact Factor: 2.01). 11/2007; 14(10):884-94. DOI: 10.1197/j.aem.2007.06.037
Source: PubMed


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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    • "Earlier reports have suggested that handoff breakdowns contribute to nearly 35% of medical errors and adverse events [5]. These errors arise as a result of a variety of communication challenges caused by differences in hierarchy, language, and general communication skills and expectations between oncoming and outgoing clinicians [6] [7] [8] [9] [10] [11] [12]. "
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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.
    Full-text · Article · Nov 2013 · Journal of critical care
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    • "Further, some participants shared that they had minimal understanding of the nature of the care provided at the other health care organization. Consistent with other literature [5,13-15,29], these findings warrant further attention as a lack of communication between settings can result in a variety of clinical errors (e.g. omission of newly ordered medications or administration of discontinued medications) and misinterpretation of expectations. "
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    ABSTRACT: Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased health care spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians' perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation health-care organizations. A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients' readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient's status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients.
    Full-text · Article · Jul 2013 · BMC Health Services Research
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    • "Versorgungsprozess garantiert werden (Apker et al. 2007). "
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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.
    Full-text · Thesis · Jun 2012
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