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Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.
The authors analyzed more than 80 communication breakdowns identified in a past review of surgical malpractice claims. The breakdowns took place with similar frequency in the preoperative, operative, and postoperative periods, and more than 70% involved a single communication failure. Attending surgeons were most commonly a part of the breakdowns, while ambiguity in the communicated roles and responsibilities contributed to more than half the events overall. Based on the findings, the authors developed a series of triggers that would prompt a direct communication with the attending surgeon. In addition, the authors advocate for greater use of structured protocols to address handoffs and transfers in care, times at which communication is critical and errors common.
Oakbrook Terrace, IL: Joint Commission Resources; 2007. ISBN: 9781599400907.
The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dangerous times for patient safety due to discontinuity of providers and care delivery. This book offers health care organizations step-by-step instructions, sample forms, and insights to help standardize the patient transfer process. The book provides tips for implementing the SBAR (Situation-Background-Assessment-Recommendation) method, which has become widely accepted as a signout tool. The Accreditation Council for Graduate Medical Education requires residency programs to address safe handoffs during training. An AHRQ WebMM commentary discussed the dangers of suboptimal handoffs.