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Cases & Commentaries
- Web M&M
Eugene Litvak, PhD, and Sarah A. Bernheim; November 2011
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
Thompson D, Holzmueller C, Hunt D, Cafe C, Sexton B, Pronovost PJ. Jt Comm J Qual Patient Saf. 2005;31:476-479.
The authors describe a tool to support reliable communication at shift change and promote improved patient safety. The project was supported by the Agency for Healthcare Research and Quality (AHRQ).
Kingston, ACT, Australia: 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.
Journal Article > Commentary
Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours have generated an expansive field of research into their impact on fatigue, workload, clinical outcomes, and patient safety. This commentary aims to put the current research into a practical context and provides eight priorities that should guide teaching institutions in their efforts to balance both physician and patient safety. The authors highlight alternative staffing models (e.g., no more 24-hour shifts), improved sign-out procedures, greater monitoring and evaluation of duty hour changes, the importance of adequate supervision and workload intensity, and better designed financial incentives to promote successful policy change. The Agency for Healthcare Research and Quality (AHRQ) has sponsored an Institute of Medicine (IOM) committee to review the important research and related issues around work hour restrictions.
Journal Article > Study
Coit MH, Katz JT, McMahon GT. J Gen Intern Med. 2011;26:28-32.
Residents working on a redesigned inpatient rotation with lower patient census completed higher quality discharge summaries compared with residents on a traditional rotation.
Journal Article > Study
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.
This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.