From Medscape Business of Medicine

Avoiding Malpractice Risks
in the Patient Handoff

Mark E. Crane

Posted: 05/10/2010

Introduction

"Achilles' heel" and "time bomb" are metaphors used to describe the handoff, that transition when patients are transferred from one doctor to another, or from an outpatient setting to a hospital or nursing home.

Problems with handoff communication are listed as one of the root causes in up to 70% of adverse sentinel events compiled by the Joint Commission. The potential for something to go wrong -- needed follow-up care that slips through the cracks or vital information that isn't communicated in a timely fashion -- can have life or death impact for patients. It's also a leading driver of malpractice lawsuits against health professionals.

In recent years, handoffs have become more troubling because of the growth in the number of hospitalists -- physicians with no prior relationship to the patient. Just 10 years ago, there were about 3500 physicians describing themselves as hospitalists. Now, there are almost 30,000 practicing in about half of the nation's community hospitals, according to the Society of Hospital Medicine.

Who is ultimately found liable for fumbling the patient handoff may be up to a jury to decide years after the event. Count on plaintiffs' attorneys suing everyone involved in the patients' care – at least initially -- regardless of their degree of accountability.

The data on lawsuits against hospitalists are sparse because these programs only formally began in 1996, but liability insurers fear that lawsuits due to miscommunication could grow rapidly. That's why they're focusing more attention than ever on studying the anatomy of the handoff and how to thwart mishaps.

Handoffs are nothing new. Every time a physician goes on vacation or gets sick, it's his or her responsibility to make sure that the covering physician is up to speed on the patients' needs. Every referral to a specialist carries the same responsibility.

As part of its patient safety goals, the Joint Commission in 2006 added a requirement that hospitals seeking accreditation standardize their approaches to handoff communication.

The need couldn't be clearer. Numerous studies have shown all sides in the handoff routinely drop the ball and fail to relay timely crucial information to colleagues. What constitutes an effective handoff is rarely taught in medical school. A 2005 study in Academic Medicine found that only 8% of schools talk about handoffs in a formal didactic session.

Neglecting to Keep Patients in the Loop

By definition, the use of a hospitalist causes a change in the flow of continuity of care. Do the patients even know that their primary physicians won't be treating them in the hospital?

"Many patients aren't aware of the handoff," says Stella Fitzgibbons, MD, a hospitalist in Houston, Texas. "There's a big difference from one practice to another. Some primary doctors set the stage for a good relationship. They'll tell patients, 'Dr. Fitz takes care of my patients while they're in the hospital, and we've had very good experience with that system. I'll be checking with her on your progress.' That's so much better than a patient who is admitted through the emergency department and then assigned to a complete stranger."

Patients should be told up front that their primary doctors won't be treating them in the hospital. "Patients don't like surprises," says Lee J. Johnson, Esq., a healthcare attorney in Mount Kisco, New York. "All of a sudden, they're being treated by a doctor who doesn't know them. If anything goes wrong, they'll be more likely to sue both the hospitalist with whom they had no prior relationship and the primary doctor whom they may feel abandoned them."

"Where's my doctor?!" was a question that many anxious patients asked internist Marica Pook, MD, of Superior, Colorado, when she started as a hospitalist 8 years ago. "We're dense with hospitalists in our state now, so patients aren't as surprised."

Once in the hospital, patients have some challenges identifying which hospitalist is caring for them because of shift changes and days off, says Jeffrey Varnell, MD, a general surgeon and risk manager for COPIC Insurance Co. in Colorado. "Some hospitals have photos of the hospitalists on the wall or even brochures so that patients can identify them more easily."

Watch Out for Dangerous Assumptions

Every aspect of the transition involved in a referral or handoff has the potential for patient injury and litigation.

Did the primary doctor make sure that the hospitalist knows of the patient's allergies? Did the hospitalist speak to the primary when the patient was admitted and discharged? Did the hospitalist convey the need for a follow-up computed tomographic scan in 3 months? Was there a delay in faxing the discharge summary? Does the patient know who he's supposed to contact if complications arise?

Sometimes, test results aren't available until after the patient has left the hospital. Perhaps a new lab finding changes the diagnostic picture or the patient's medication regimen. Maybe an x-ray was misinterpreted. "If something is outstanding, it's the hospitalist's responsibility to find it out and transmit it to the primary doctor," says Dr. Pook. "You can't just assume the information will be conveyed."

A false assumption, lack of documented instructions, and confusion about follow-up care can lead to medical disasters. "I recently saw a case involving a man with syncope who insisted on leaving the hospital once the neurologic work-up was complete," says Dr. Fitzgibbons, who reviews malpractice cases for attorneys. "His family physician never received the hospital notes, so the patient didn't get a cardiac stress test before his fatal MI [myocardial infarction]."

For another patient, echocardiogram (ECG) results showing that he needed a longer regimen on antibiotics weren't transmitted to the nursing home, says Dr. Varnell. The patient developed an infection in his spine, resulting in permanent paraplegia.

"EMRs [electronic medical records] may change the landscape, but most physicians don't have full systems yet and there's no universal format. In places where primary doctors and hospitalists have compatible EMR systems, a patient's records will be accessible to both parties. Even so, risk managers say it's still incumbent on physicians to speak with each other rather than just assume that each has checked updates on the patient's records."

If something goes wrong, both the hospitalist and primary doctor will be sued. The duty to provide adequate follow-up is shared, says Dr. Varnell. It's a poor defense in a malpractice case to argue, "I assumed the hospital (or the primary) was handling that," when the injury could have been prevented if the 2 sides had communicated better. Jurors are rarely forgiving when physicians point fingers of blame at each other.

What Physicians Owe to Each Other -- and Patients

The patient's primary doctor should call the hospitalist directly and clearly state why the patient needs to be admitted, the patient's medications, and any known allergies, says Dr. Pook.

"We need a legible problem list that includes his previous surgeries and hospitalizations. Remember, we're seeing the patient for the first time. Make sure we have contact information on how to send him back to the primary and please send along that concerning ECG that caused you to send the patient in the first place," she says.

Dr. Fitzgibbons agrees: "The burden is on the primary to send a complete summary of important points and a medication list. That isn't always possible if the patient is admitted at 2 AM but we need it as soon as possible."

What the hospitalist owes the primary doctor is crucial because so many mishaps occur due to miscommunication about follow-up. "We should email or fax a thorough discharge summary and call the physician directly," says Dr. Pook. "We should review all pertinent tests and results, which specialists saw the patient, and what the follow-up plans are."

It's best for doctors to speak directly with the other doctor because there will be less chance of things going wrong. At some hospitals, it's a rule for doctors to speak; at others, it's considered OK to leave a message with the staff. However the communication takes place, it should be documented, such as, "left message with Dr. primary's office," "spoke to Mary," "need for follow-up chest x-ray in 3 months."

To protect themselves from liability, hospitalists must document that phone call, note who they spoke with, and what was said. "Part of the trouble in communication is that medicine is still practiced like a cottage industry," says Dr. Pook.

"Everyone has a different system for electronic records or paper charts. Some doctors like emails; others want phone calls. There's no unified system. We try to tailor the discharge to the needs of each primary doctor."

Sometimes a patient needs to be seen within 10 days for follow-up, says Dr. Fitzgibbons. "But he may have trouble getting an appointment if the office or the doctor is busy, so appointments may not be available right away. The hospitalist should intervene if the patient needs to be seen sooner."

Discharges are a liability minefield, risk managers say. Researchers from Mount Sinai School of Medicine in New York, NY, found that more than one third of recommended outpatient work-ups following a patient's hospitalization were not completed. Why? The discharge summary didn't include details of the work-up, or the summary wasn't available to the primary doctor at the time of the patient's follow-up visit.

Researchers also found that changes to patients' medications may go unnoticed by their primary doctor after discharge. In 11% of cases, patients had test results pending at discharge that turned out to be abnormal, but their primary doctor was unaware of these results, according to the study in the June 25, 2007 issue of Archives of Internal Medicine .

Do You Know What Drugs the Patient Is Taking?

"Many physicians really don't know what medications their patients are taking," says Dr. Pook. "Patients see several specialists and go to different pharmacies. Then they come to the hospital and are put on different meds. The need for medical reconciliation is tremendous, but it varies from hospital to hospital, doctor to doctor."

"Often, the family comes to the hospital with a grocery bag filled with grandma's pills," says Dr. Fitzgibbons. "Then the family comes back the next day with a second bag. It's a horrible way to do things."

The Joint Commission in 2005 began to require that hospitals develop processes for medical reconciliation, but a uniform system doesn't exist yet: "Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking."

This reconciliation is done to avoid medication errors, such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten," the Joint Commission notes.

The process involves 5 steps:

Reconciliation can spur dramatic improvements. Pharmacy technicians at one hospital reduced potential adverse drug events by 80% within 3 months by obtaining medication histories of patients scheduled for surgery, the Commission notes.

The sentinel event database includes more than 350 medication errors resulting in death or major injury. Of those, 63% related, at least in part, to breakdowns in communication, and approximately half of those would have been avoided through effective medication reconciliation.

Key Steps to Make the Handoff Smoother

There are plenty of resources to help physicians and hospitals to improve communication about handoffs. One method is as simple as a read-back from your colleague to make sure that you're on the same page. For example, the receiving physician may say, "OK, this is an 84-year-old woman with metastatic liver disease and she's getting a dose of 500 mg of morphine." At this point, the referring physician can correct an error and say, "No, No. It's 50 mg of morphine."

Direct conversation between doctors is superior to relying on electronic forms to get the big picture. It allows each doctor to ask questions and confirm instructions.

"The bottom line on handoffs is similar to basic risk management advice about all areas of potential malpractice: Communicate and document," says attorney Lee Johnson.

COPIC has provided physicians with some practical suggestions:

Authors and Disclosures

Author(s)

Mark E. Crane

Freelance medical writer, Brick, New Jersey

Disclosure: Mark E. Crane has disclosed no relevant financial relationships.

-From: http://www.medscape.com/viewarticle/720961_6 retrieved 5/19/10

 

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