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Cases & Commentaries
- Web M&M
Elizabeth A. Henneman, RN, PhD; May 2007
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
Journal Article > Study
Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-2912.
Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.
Journal Article > Study
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.
Orenstein EW, Ferro DF, Bonafide CP, Landrigan CP, Gillespie S, Muthu N. JAMIA Open. 2019 Aug 7; [Epub ahead of print].
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.