Considering the insane amount of consecutive hours worked by doctors, it comes as no surprise that patient details can get lost in the shuffle due to human error from overly exhausted nurses, doctors, and healthcare staff, during these shift handoffs.
This could prove to be a huge patient safety risk.
The looming question remains: why hasn’t there been any emerging technology that allows for the seamless conveyance of key patient information?
A recent article by Shefali Luthra shines light on a research letter that analyzed the results from an innovative web-based tool meant to improve communications among the doctors, nurses and other health care providers at Brigham and Women’s Hospital, with the goal of mitigating loss of critical patient data during the handoff at shift changes.
“[...] there remains a lack of rigorously performed studies that help guide best practices in handoffs of hospitalized adult patients. In this study, we implemented a web-based handoff tool and training for healthcare professionals, and evaluated the association of the tool with rates of medical errors in adult medical and surgical patients.”
Researchers targeted and surveyed residents at the end of their shifts who worked the “twilight” (4 p.m. to 12 a.m) and “nightfloat” (midnight to 7 a.m.) in order to evaluate the tool. Possible medical errors were then collected, and then rated based off of how avoidable they actually were. Surveys started three months before the tool’s February 2013 inception. The comparison of errors spanned from before inception, through one year following, examining more than 5,000 patient cases, and the results were compelling.
Reducing human error
Between November 2012 and February 2013 there were 77 errors identified, and only 45 in the following year - a reduction of more than forty percent.
“This shows that [an electronic patient record] can help mitigate medical error,” said Dr. Stephanie Mueller, the study’s main author and an associate physician in primary care and general internal medicine at Brigham and Women’s Hospital.
Brigham and Women’s Hospital realized the significance of having a strategic plan in place for a new technological integration. With a comprehensive educational training included, they were able to accomplish a seamless integration and adoption rate among staff members.
“This can be used as a model for what other health care institutions can do. … It gives a really good argument for what can be done,” said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. He was not involved in the study.
The unique software used by Brigham and Women’s Hospital was written in-house, and integrated with their commercially produced electronic health record.
Researchers believe that they’ve tapped into a new path that can be perfected and implemented in the handoff protocol throughout healthcare addressing an industry-wide inefficiency of the conveyance of pertinent key patient data at crucial shift change handoffs.
Aptly named, Enclothed Cognition is the official Medelita blog for medical professionals interested in topics relevant to a discerning and inquisitive audience. Medelita was founded by a licensed clinician who felt strongly about the connection between focus, poise and appearance.