Improving Patient Hand-Offs with Three Strategies


Patient hand-offs are prime times for errors to occur, but departments and hospitals can take steps to make these moments safer.

What is potentially the most dangerous time during a patient’s care? If you answered “the hand-off,” you’d be right. And, communication failures are typically to blame.

Nearly 80 percent of medical errors occur due to communication gaps that typically occur when patients are transferred from one department or physician team to another. Radiology is no different, and in a May 11 article published in the Journal of the American College of Radiology, a team of investigators from Montefiore Medical Center in New York City laid out the case for making improvements.

“In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care, such as determining protocol, imaging, interpreting, and consulting,” said the team led by Judah Burns, M.D., director of the diagnostic radiology residency program at Montefiore, noting that significant communication challenges exist for both interventional and diagnostic radiology. “The frequency of hand-offs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department.”

While there has been extensive research into patient transitions in surgery, medicine, and nursing, there’s been little work concentrating on radiology. But, miscommunications around imaging choices, protocols, and follow-up guidance can potentially lead to patient harm and litigation vulnerability for the provider.

“Communication failures in these moments are among the top five causes of litigation against radiologists with higher rates of indemnity payments awarded because delayed or missed diagnoses from these communication failures result in significant patient morbidity and mortality,” the team said.

For radiology, the main mode of communication is the written report. But, if they contain vague diagnostic details or follow-up recommendations, miscommunications are more likely to happen. In addition, the team said, existing research shows confusing transcriptional errors occur in as many as 22 percent of reports, and there is evidence that many providers do not fully read the reports anyway. Consequently, there is a critical need for radiology to improve patient hand-offs.

In order to do that, Burns’ team offered guidance on three strategies to improve communication.

Individual behaviors: Human errors are common, so practices must train staff on where those mistakes are most likely to occur – order requests, transcriptions, or inattentiveness. To decrease the likelihood of an error, the team recommends staff take notes, repeat back information, make checklists, share computer screens, and conduct virtual consultations.

Team behaviors: Put a plan in place for hand-offs rather than conducting them unprepared, including having a safety checklist. Make sure hand-off areas are relatively quiet as a way to improve communication and limit interruptions.

Organizational behaviors: To streamline hand-offs and reduce opportunities for error, consider automating exam orders, reporting, and reminders. Be sure to prioritize patient safety as a fundamental principle in the facility, the team said.

Taking these steps is a vital part of improving the hand-off process within hospitals and between departments, the team said. In addition, it can significantly contribute to higher quality patient care and patient safety.

“Hand-offs play a critical role in our ability to provide patients with quality care, but they remain a major communication challenge and source of error among medical professionals,” the team said. “Understanding hand-offs in radiology allows us to enhance patient safety, transition radiology practices toward high-reliability organizations, and advance our application of health systems science by adding value to radiologic care.”

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