Hard to Handle

In 2008, Massachusetts General Hospital (MGH) published findings from an internal study on the effectiveness of patient handoffs within the Boston, MA-based teaching facility. The results weren’t pretty; lead researcher Barry Kitch, MD, MPH, and colleagues determined that of the 161 residents who completed a survey designed to analyze residents’ experience with handoffs and their perception of how often handoffs were a factor in adverse events, 58% reported at least one incident of handoff-related patient harm during a month-long inpatient rotation. Even more alarming was the fact that 12% of residents reported that the harm had been major, a category that included significant worsening of clinical status, prolonged hospitalization, disability, or death.But what was perhaps just as critical as these findings was MGH’s response. Using the results as a catalyst, the organization launched an initiative to improve the safety and effectiveness of its handoff process. We spoke with Andrew Karson, MD, MPH—who served as an investigator on the original study and was tasked with overseeing the handoff-improvement projects—about what MGH learned and what are the plans going forward.

Based on what you’ve seen, what are the biggest challenges in terms of patient handoffs?

I would say the time it takes to prepare and receive a good handoff, and to have it protected. And the fact that there’s a lack of standardization in what the protocol should be, and what the content should be around a handoff.

Those are probably the biggest challenges—especially in the setting of a very complicated work environment. It’s very fast-paced, and in general, it’s a situation where people are under extreme time pressure with a lot of competing priorities.

What is the first step that can be taken to improve handoffs?

I think having standardized approaches and expectations around handoffs is critical. In other industries—and aerospace is often used as an example when we talk about quality and safety—when you have sensitive, high-risk situations when there is a handoff from one person to another, there are protocols. But in healthcare, there is a lack of standardization around handoffs—both in the industry as a whole, and even in individual institutions.

So the big question is, what can be done to address this issue?

Well first of all, handoffs don’t always even happen. So that’s kind of the low-hanging fruit. Handoffs need to occur. The second thing is that when handoffs occur, sometimes there is missing information that the person receiving the handoff would have liked to have had. And then at times, there’s misinformation; it could just be a simple mistake in content, or the information could be outdated.

One solution that some facilities are using is an electronic computer-aided handoff process.

That brings up an interesting point. What role can technology play in improving the handoff process?

As far as technology goes, I agree 100% that there is a role, and I would even say a critical role, for technology in making handoffs more standardized, because it always aids in standardization if there are fields for attending of record, code status, life-sustaining treatment status, things like that.

Technology is critical. The types of things it can do is to standardize, and make sure there are either required fields or reminder fields so that if I see ‘code status’ in a field, that might trigger me to enter, ‘this person is do not resuscitate for X reason,’ or it can alert me if there’s an allergy field or critical medication issue field. So if there’s a trigger, for example, if an institution feels something is so critical that it should be considered in every handoff, then technology can be used to help structure that, with either reminders or required elements.

Technology can also pull things in, and that decreases redundancy. For example, if I have a system that can pull in the anticoagulants the patient is on, or if the patient has an order in our hospital system of life-sustaining treatment or code status, and it could pull it in for me, I don’t have to rewrite it or retype it in.

And there’s also the whole concept of over-information. So I’m handing off 15 patients to you at night, and I have a book written on each one of them, that’s not very helpful when a nurse calls in the middle of the night and says someone is short of breath. If it’s too much information, whether it’s technology-driven or if it’s because they took a half-hour signing out and they gave you way too much information, you can lose the important parts. Finding the right balance of the right amount of information is a challenge to some extent, and technology can make that either better or worse, depending on the technology and the users.

How did the idea for the MGH study on patient handoffs come about?

Going back a little bit, in 2005-06, the Joint Commission came out with patient safety goals specifying that handoffs had to have structure, and one of the stipulations was that there needs to be an opportunity during handoffs to ask and respond to questions.

The reason for the our survey was that Peter Slavin, MD, president of Mass General, and Gregg Meyer, MD, our senior VP of quality and safety, said in response to the Joint Commission’s goals, ‘That’s interesting—how are we doing with handoffs?’ There was a lot of anecdote, but we didn’t really have any specific internal data on handoffs. It wasn’t actually meant to be a research study, but it prompted an internal survey where we just wanted to know from our own house staff how problematic handoffs are. And to hear that 58% of them said there was at least minor harm, and 12% said major harm in the previous month—that really opened our eyes.

How did MGH respond to those results?

It started a whole list of actions. One, we developed a new policy around handoffs, and we educated physicians and nurse at all levels through seminars and through various print newsletters and things of that sort. Our trainees attended very specific lectures around handoff safety and best practices around handoff safety; all of our various orientations to our new interns and to our new fellows included a very specific mini-curriculum around handoff safety and best practices as we understand them.

There’s not a lot of research out there on what is a best practice; there’s a lot of opinion and expert guideline, but there aren’t many specific studies saying ‘this element is really helpful and that element is not.’ But things that have been found to important are the fact that there should be at least a verbal communication, it should be face-to-face, and you should focus how to handle potentially unanticipated events for a patient.

Basically, we had multiple different vehicles for letting people know this new policy—various lectures, talks, seminars, and a lot of trainee education to really make people aware that handoffs are unsafe. One of the interesting things about the study was that everyone knows that medications are potentially unsafe—there’s a lot of literature on adverse drug events and people getting medication overdoses or meds that they’re allergic to, and the drug safety literature is really robust. But the study led by (Barry Kitch, MD) showed that if you believe the perception of our house staff, the amount of harm caused by handoffs was about on the order of magnitude of drug safety. We worry so much about drug safety—we have provider order entry, we have eMAR, and we have medication safety officers everywhere. But with handoffs, no one really knew how unsafe they were.

So every piece of education had two parts: one is awareness—handoffs can be very unsafe, here’s our own internal data showing that our own house staff is worried. And two is, here’s what you can do about it: make sure you have handoffs; make sure that they’re verbal and, very importantly, that there is opportunity to answer and respond to questions; make sure to include key elements of their care; and include information on how to handle unanticipated events—if you can, share that.

After launching these educational and process improvement initiatives, were you able to realize improvements in handoffs?

Yes, we’ve made significant improvements. We have a recent survey that we’re just analyzing now, and it shows that there has been a significant reduction in the perception of problematic handoffs. The results of the survey aren’t available yet, but I’ve been told that we’re seeing the concern of patient harm due to problematic handoffs has significantly reduced in the last four years.

Resources on Patient Handoffs

• The National Transitions of Care Coalition
• Institute for Healthcare Improvement (IHI) Perioperative Patient Handoff Tool Kit
• AORN Patient Handoff Toolkit