As healthcare providers strive to make care safer for patients, there is often a failure to communicate. In fact, lack of communication is the single most common root cause factor that leads to liability claims.

The primary objective of a handoff is to provide accurate information about a patient’s care, treatment, services, current condition, and any recent or anticipated changes. Handoffs are interactive communications allowing the opportunity for questioning between the provider and recipient of patient information.

Appropriate communication among physicians, nurses and all other caregivers is essential in preserving the continuity of care. When communication is poor, this may cause patients to question the very quality of care they receive.

In the 2005 study Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, coauthor Richard M. Frankel PhD, Professor of Medicine at the Indiana University School of Medicine, indicated that an efficient and safe patient handoff often does not occur probably because physicians—unlike air traffic controllers and others who perform vital handoffs—do not receive adequate training on how to communicate during these transfers of responsibility and across different information systems. “Our study poses two very basic questions. First we asked: ‘Can we afford to spend the time, effort, and dollars involved in additional training of physicians?’ And then we asked: ‘Can we afford not to?’ ” wrote Frankel.

Teamwork Needed
Physicians practice as part of a team, and communication from one to another can be a challenge. It is sometimes tempting, for example, to engage in jousting in the chart: A nurse writes one observation, the physician notes a conflicting observation, and a consultant offers yet a third one. Avoid these kinds of squabbles because no one wins except plaintiffs’ lawyers, who seek to divide and conquer. Instead, be open and honest—yet discrete—while communicating, not only with colleagues but with patients and staff as well.

For hospitals, the handoff has long been considered the ticking time bomb of healthcare. Dangerous errors and oversights can occur in the gap when a patient is moved to another unit or turned over to a new nurse or doctor during a shift change. Bungled handoffs can range from a patient getting a second, unneeded dose of a medication to doctors reviving a patient because they were unaware of a “do not resuscitate” order.

The Joint Commission now requires hospitals to establish standards for handoff communications, breaking down the long-standing professional barriers in the exchange of patient information between doctors and nurses. The stakes are high since hospitals that fail to comply with Joint Commission patient safety standards risk losing their accreditation, which is often required to receive Medicare and third-party-payer reimbursement.

Avoiding Errors
Examples of inadequate handoff communications are also prevalent in the ambulatory care setting. Shorter hospitalizations and the increased number of outpatient procedures present new risks for physicians and patients. The amount of time available for monitoring possible complications and for providing patient education is reduced. Consider the following:

• Make a follow-up phone call to the patient on the evening of the surgery. This will help to clarify any instructions given earlier and provide an opportunity for the patient to ask specific questions regarding pain, fever and complications. Document the telephone call in the medical record.
• If a post-procedure follow-up appointment was not arranged prior to the procedure, have your office call the patient the following day to schedule it.
• If the physician performing the procedure is not the one who will be giving the follow-up care, make sure the responsible provider is very clear about his or her role in treating the patient.

Referring Physicians
Failure to ensure adequate communication among providers may also result in a patient’s failure to undergo needed specialty evaluation and testing. The following suggestions for referring physicians can help improve communication and the level of care that the patient receives.

• Call the consultant directly. The urgency of the consult may not always be appreciated if the treating physician only writes an order for the patient to be seen. Communicate the reason for the referral and confirm that the consultant will accept the patient. Document this discussion in the medical record.
• Follow up the phone call with written communication, reiterating the specific consultation request.
• Relay the results of imaging or lab tests to the consultant.
• Request that the consulting physician forward a copy of his or her findings to your office. If you do not receive the report within a specified time frame, contact the consulting physician.
• Flag the patient’s medical record as a reminder to review referral findings with the patient at his or her next visit.
• Take responsibility for coordinating additional referrals to other consultants.

After-hours calls carry a special risk because the physician is making clinical decisions based solely on information provided by the patient, the patient’s family members or, possibly, another healthcare professional. Always provide detailed communication with the physician for whom you were covering. Tell the physician if you recommended that his or her patient obtain any follow-up or further evaluation or treatment. Also, inform the physician if the patient is expecting further follow-up.

In documenting telephone calls with other healthcare providers (e.g., emergency, on-call and primary physicians), include the reason for the call, patient-related information communicated, requests for on-site evaluation, and requests for management or follow-up plans. Also, a tracking system for missed appointments, diagnostic tests, and consultations is an excellent documentation tool to enhance the patient’s continuity of care as well as to avoid any breakdown in the handoff process.

Communication breakdown is the single largest source of medical errors. Improving the handoff procedures in both the hospital and ambulatory care environment will not only provide safer care for patients but will help reduce the liability risk for healthcare providers.