To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Policy. 2015;20:17-25.
Patient handoffs are a major challenge for patient safety, especially when patients move between different units or organizations. Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality of handoffs.
Meisel ZF, Shea JA, Peacock NJ, et al. Ann Emerg Med. 2015;65:310-317.e1.
This focus group study with emergency medical services personnel identified several potential ways to improve the quality of handoffs between paramedics and emergency department staff. A structured handoff tool has been developed to address this known safety hazard.
Balka E, Tolar M, Coates S, et al. Int J Med Inform. 2013;82:e345-57.
This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-33.
Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.
Greenwood MJ, Heninger JR. Prehosp Emerg Care. 2010;14:345-8.
This article describes a case where lack of clarity in communication contributed to the death of a patient and highlights strategies to prevent similar failures, including read back and critical assertion.
Arora V, Johnson J, Lovinger D, et al. Qual Saf Health Care. 2005;14:401-7.
The authors interviewed interns to understand communication failures with patient transfer processes. They suggest improvements for verbal sign-out and propose that these improvements be used in designing educational programs on effective communication.
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