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.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.
Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-61.
This study evaluated nearly 300 adverse events that occurred during intrahospital transport, noting that equipment problems and hypothermia were the most common. Investigators combined 6 months of prospective observation with retrospective chart review to characterize the type and nature of events recorded for patients admitted to the intensive care unit from the emergency department. While the overall rates were lower than reported in past research, the authors advocate for using their findings as benchmarks: an adverse event rate of 22 of 100 transfers and 38 of 100 delays in transfer. A case commentary on Agency for Healthcare Research and Quality (AHRQ) WebM&M discusses the issue of intrahospital transport with suggestions for improving the safety of this poorly studied process.
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