Dahlberg B. Kaiser Health News. September 29, 2020.
This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.
Smeulers M, Lucas C, Vermeulen H. Cochrane Database of Syst Rev. 2014;6:CD009979.
Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This systematic review sought to determine effective interventions to enhance nursing handoffs. Although several studies have examined handoff techniques that nurses used, there is no evidence to indicate whether verbal handoffs, chart-based handoffs, or handoffs including patients or family are associated with improved patient outcomes, echoing a prior systematic review. The authors recommend that nursing handoffs be structured, include face-to-face communication, involve patients, and utilize health information technology. They also call for studies to compare different approaches in order to achieve an evidence-based best practice. A past AHRQ WebM&M commentary describes the consequences of an incomplete nursing handoff.
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