The Legal Perils of Patient Handoffs

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The Legal Perils of Patient Handoffs
A MICA Risk Management Presentation
Karen Connell, RN, BSN, MA
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Objectives

• Participants of this presentation will be able
  to
• Discuss the role of ineffective handoffs in
  prompting malpractice claims and suits.
• Identify strategies for improving information
  transfer at points of transitions in care.
• Utilize recognized mnemonics to prompt complete,
  effective transfer of critical information in the
  patient handoff process

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Who Dropped the Ball?

• Failure to diagnose is a leading cause of loss.
• 25 of diagnosis-related malpractice cases were
  due to failures in follow-up.
• Communication Breakdowns are cited as causative
  factors in 65 to 80 of cases.

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Who Dropped the Ball?

• Failure to follow up on abnormal diagnostic test
  results is a critical weakness in many suits,
  especially in outpatient care settings.
• One study found that 75 of physicians did not
  routinely notify patients of normal test results
  and
• 33 did not always notify patients about abnormal
  test results.
• Lawsuits alleging failure to communicate
  radiology results are particularly prevalent and
  growing.
• In nearly 60 of these suits, the referring
  physician was not directly contacted about urgent
  or clinically significant unexpected findings.

Ghandhi, T, MD, MPH, Fumbled Handoffs One
Dropped Ball after Another, Ann Intern Med
2005142352-358)
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Creating a Fail Safe Process Critical Test
Results

• Identify to whom test results should be sent.
  (Who ordered the test?)
• Define which results require expedited, reliable
  communication and maintain a prioritized list of
  critical test values
• Define appropriate notification time parameters
  for communicating critical test results.
• Identify reliable communication methods.
• Develop a fail-safe plan for communication
  critical test results when the ordering or
  covering provider cannot be reached.
• Create tracking systems to measure reliability of
  the system.
• Ensure acknowledgement of receipt of test
  results by a provider who can take action.

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Creating a Fail Safe Process Critical Test
Results

• The role of the patient
• Avoid the traditional No news is good news
  philosophy.
• Patients/families should be anticipating results
  and prompt clinicians when no news is received.
• This should NOT however be the primary criteria
  for communication merely a backup for
  formalized plans of communication.

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Malpractice A Team Effort

• While an allegation will seldom read poor
  teamwork there are many claims where delayed
  diagnosis or other medical errors can be traced
  to poor coordination of care or miscommunication.
• One large insurer noted 300 claims involving
  inadequate communication or coordination of care
  issues paid out over 100,000,000 in the last
  decade. (Forum, Harvard Risk Management
  Foundation, 7/03)
• Miscommunication in these cases often occurs at
  some point of hand-off often across
  disciplines.

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Lawsuits Demonstrate Missed Opportunities

• Looking back, we usually find
• A CONCERN was expressed.
• The PROBLEM was not stated clearly.
• A PROPOSED ACTION didnt happen.
• A DECISION was not reached.

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Medical Error - A Team Effort

• The need for a structured handoff process was
  prompted by several studies that focused on the
  root causes of sentinel events and poor medical
  outcomes across the continuum of care.
• These revealed that a majority of avoidable
  adverse events were due to the lack of effective
  communication and involved
• Lost information
• Misinterpretation
• Misdirected or missed actions.
• The Joint Commission in 2006 mandated that
  accredited organizations implement a standardized
  approach to transitions of care.

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Liability Pitfalls with Hospitalist Model

• Failure to communicate with PCP on admission
  associated with
• Incomplete history patient may be poor historian
  or too sick to provide adequate information.
• Patients necessary medications may not be
  continued.
• Underlying health concerns may be overlooked.
• Psychosocial issues within the family may be
  unknown and complicate care or discharge planning.

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Liability Pitfalls with Hospitalist Model

• Failure to communicate with other inpatient
  physicians may fragment care and lead to poor
  health outcome.
• Failure to communicate unresolved diagnostic
  findings to PCP for follow-up leads to failure to
  diagnose claims/suits.
• Failure of PCP to review materials sent by the
  hospitalist may also lead to poor health outcomes
  and failure to diagnose claims/suits.
• Failure on the part of the PCP to follow up has
  also been viewed as abandonment.

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Role Confusion

• Patient expectations unmet - Wheres my doctor?
• Patient not expecting to see a stranger.
• Patient unaware of role (or existence) of
  hospitalist.
• Plan of care patient discussed with PCP may
  differ under the hospitalist.
• Patient may be reluctant to consent to care from
  someone they do not know or trust.

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Clarify - Who Does What?

• Role of PCP
• Educate patients as part of general care that if
  ever hospitalized may be under care of
  hospitalist.
• Will there be social visits or calls?
• Ongoing contact with hospitalist?
• Who initiates?
• Notification at admission and discharge?
• Be alert for hospital faxes and have system in
  place to be sure discharge notes and diagnostics
  are not filed without being seen by the
  physician.

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Clarify Who Does What

• Role of the Hospital
• Work with hospitalists to establish policies and
  procedures, such as
• Identify PCP within ___ hours of
  admission.
• Use health plan as resource where possible.
• For ER admission, fax ER records within ___hours.

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Who Does What Hospital

• Include identification and notification
  procedures as part of routine orders?
• Policy for phone contact with PCP if patient
  unable to provide history. who calls Hospital
  Staff? ER? Unit? Hospitalist?

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Who Does What Hospital

• Work with healthcare team to reasonably
  anticipate discharge.
• Timely notification of PCP how? who?
• Fax discharge and follow-up info in reasonable
  timeframe to protect patient well being.
• Clear policies designed to anticipate discharge
  needs of patients with no PCP.

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Who Does What The Hospitalist

• Determine who is responsible for initiation of
  communication with PCP? Hospital staff?
  Hospitalist?
• If the PCP is not part of the inpatient care
  must still be viewed as an important source of
  information necessary to care.
• Verify appropriate communication strategies are
  in place.
• Individualize appropriate form of communication
  based on patient need. Fax? Phone call?

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Whos in Charge, Anyway?

• Who really has ultimate responsibility for the
  inpatient care?
• Is the hospitalist serving as one of several
  consultants? (i.e.. serving as an internal
  medicine consult on a surgical or orthopedic
  patient?)
• Is all care to be coordinated by the hospitalist?

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Whos in Charge, Anyway?

• How many hospitalists will the patient see? If
  multiple whose plan prevails?
• If not clarified, patient can suffer harm or, at
  the least, frustration.
• Is there a plan for resolution of problems where
  a PCP, specialist or hospitalist have conflicting
  treatment plans?

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Discharge Planning

• Need to forecast discharge and anticipate
  possible post hospital problems.
• Patient going home while still unable to care for
  self makes surprises unacceptable.
• Communication and collaboration with all health
  team members is crucial.

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Study Shows Post-hospital Problems

• 15 patients had adverse events after discharge
  not associated with the underlying disease.
• 2/3 were from drug side effects
• Asthmatic patient sent home on beta blocker
• Failure to arrange for help at home
• Failure to follow-up timely on diagnostic results
  discovered after discharge
• Study concluded most problems could have been
  prevented with better communication and
  pre-discharge planning. Feb. 2003 Annals of
  Internal Medicine

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Perils of Friday Discharge

• Researchers say more patients leave the hospital
  on Friday than on any other day.
• Study showed patients discharged on Friday were
  more likely to die or be readmitted w/in 30 days.
• Patients likely experienced problems coordinating
  post-hospital care over the weekend, and may have
  had the start of home-care services delayed until
  Monday or Tuesday.
• They may also have had problems contacting their
  family physician in the event that they have an
  urgent problem.

Can Med Assoc Journal 20021661672-1673.
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Before they Leave Do they Know?

• What health problems do I have and what should I
  do about them?
• How should I take my medicine?
• When do I take it?
• What will it do?
• How do I know it is working?
• What is a bad reaction and what do I do?
• Who do I call if I have questions?

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Before they leave, do they know?

• Other instructions
• What do I do?
• How do I do it?
• When do I do it?
• Next steps
• When do I need to see the doctor?
• Who do I see? Do I have an appointment? What
  day? What time?
• Are there phone numbers to call if I have
  problems before I see a doctor?

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Effective Handoffs/transitions

• Provide for interactive communications which
  allow the opportunity for questioning.
• Include up to date information regarding
  treatment, services, condition and any recent or
  anticipated changes.
• Interruptions limited.
• Require process for verification.
• Receiver has opportunity to review relevant
  patient historical information including previous
  records.

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I P.A.S.S. the B.A.T.O.N.

• A mnemonic for handoffs and healthcare
  transitions developed to cover the key areas for
  both simple and complex patient care handoffs.
• Offers a foundation for clinical leaders to teach
  others on how to conduct a proper handoff.
• Used to remind clinicians of the key information
  and factors to include during their medical
  handoffs.

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I P.A.S.S. the B.A.T.O.N.
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I P.A.S.S. the B.A.T.O.N.
THE
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Briefings Key Elements

• Involves others.
• Explicitly asks for input.
• Asks knowable information.
• Shares information with others.
• Names names.
• Makes eye contact face the person.
• Emphasizes responsibility to offer input.
• Uses appropriate assertion.

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Encourage Briefings

• Handoffs
• Shift change
• Significant new information
• Situational
• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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SBAR example

• Situation Dr. Brown? Im Mary Smith the med
  student on 2 West. I want to talk to you about
  Mrs. Jones in room 251. Chief complaint is
  shortness of breath of new onset.
• Background She is a 62 year old woman first day
  post op left hip replacement. No prior history of
  cardiac or lung disease?

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SBAR Example

• Assessment Breath sounds are decreased on the
  right with pain. Id like to rule out pulmonary
  embolus.
• Recommendation I feel strongly the patient
  should be assessed now. Would you come with me
  to see her?

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Avoid Offhand Handoffs

• STARS model for briefings
• Situation give a framework so the receiver
  understands the context.
• Timing Express the degree of urgency (time) or
  the frequency (repetition) for action.
• Action What are the specific actions to be
  taken?
• Responsibility Who is to do what? Name names.
  Dont use pronouns.
• Summarize Boil it down into one or two
  sentences.

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STARS Model

• S Dr. Gordon, Dan Smith here. You are on call
  tonight, correct? Im concerned about the amount
  of bleeding in patient Mary Brown who I did a TAH
  on this morning. She is up on 5 West. Her wound
  is oozing. I thought for a while I might have to
  take her back to the OR. I checked him at 4p but
  she needs a recheck and Im due at the airport in
  a few minutes.
• T This is urgent, or I wouldnt bother you.

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STARS Model

• A - Would you please see Mrs. Brown before you go
  home tonight, say by 6pm and be sure the bleeding
  is under control? If theres any chance shell
  need to go to the OR, please notify Nancy the
  supervisor by 7pm. Ill call you when my plane
  gets in to see how its going.
• R Sorry, Im out of pocket for tonight but
  youll handle the recheck and open her up if
  necessary, right? Her sister is at the bedside so
  please fill her in.
• S- Great, Ill tell the nurses you will see Mary
  Brown on 5 West before 6p and call the OR
  supervisor by 7pm if you think shell need to go
  back to the OR. Shell put things in motion.
  Ill check in when I can. Tell Mrs. Brown I said
  shes in good hands. Thanks.

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Debriefings

• An opportunity for individual, team and
  organizational learning.
• At the end of the day, shift or procedure, those
  involved can spend two or three minutes talking
  about how did it go?
• The more specific, the more valuable.
• What went well?
• What was difficult?
• What could we have done differently?
• What did we learn?

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Bottom Line

• Miscommunication is at the heart of many medical
  errors that result in expensive malpractice
  claims and suits.
• Improving follow up strategies, particularly on
  critical lab values will reduce adverse outcomes.
• Taking a more structured approach to transitions
  of care including hand offs is a key safety
  strategy.

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Questions?