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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

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.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.
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.
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.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.
Kingston, ACT: Australian Medical Association; 2006.
This report outlines best practices for patient transfer and shares experiences from the field for Australian physicians and health care organizations that seek to improve their handoff processes.
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.