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PSNet: Patient Safety Network
Journal Article

Association between end-of-rotation resident transition in care and mortality among hospitalized patients.

Denson JL, Jensen A, Saag HS, et al. JAMA. 2016;316:2204-2213.

Handoffs are ubiquitous in hospital care and a recognized risk factor for adverse events. Most research on handoffs has focused on care transitions from the primary clinician to a covering clinician, but studies have also demonstrated the potential for harm associated with changes in the entire team of care (such as at the end of the academic year). In academic hospitals, clinician teams switch on a predictable schedule, often at the end of the month, when residents complete a rotation. This study analyzed the outcomes of more than 200,000 inpatients at Veterans Affairs hospitals to determine if end-of-rotation team changes were associated with clinical harm. Investigators found a striking increase in in-hospital mortality among patients whose hospitalization spanned the end of a rotation (and thus were exposed to a resident team change during their hospital stay), which persisted for up to 90 days after discharge. The accompanying editorial notes that some of the mortality increase may be accounted for by the fact that patients who are more seriously ill and have longer hospitalizations may have been at higher risk of death independent of the team change. Nevertheless, since there are no standards for patient handoffs at the end of a rotation, poor information transfer or cognitive heuristics (such as anchoring bias) may have led to preventable adverse events. The editorial authors advocate for more research into the mechanisms of this mortality increase and the development of standards analogous to the I-PASS signout format for end-of-rotation handoffs.