Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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8 System Strategies to Improve Patient Safety and Error Prevention
8 System Strategies to Improve Patient Safety and Error Prevention
Pages 263-294
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From page 263... ...
The committee's examination of graduate medical education has revealed that duty hours represent only one among many factors in residents' experiences that may affect patient safety and resident learning. Although the committee's deliberations about recommendations to help mitigate and prevent resident fatigue were central to its charge, it became apparent that additional changes at the system level could also help improve patient safety, resident education, and the quality of care.
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From page 264... ...
. The committee builds on those earlier reports, focusing attention on adopting strategies for teamwork development and error reporting to better serve the educational needs of residents while fostering safe patient care.
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From page 265... ...
Although recognition of a safety culture and high-reliability components and practices (e.g., teamwork, blame-free error reporting) are becoming more common in health care, there has yet to be widespread adoption of these practices across the medical field (Patterson et al., 2004)
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From page 266... ...
Reducing Errors by Improving HANDOVERS Handovers, or transitions in patient care are an area of medical practice that is considered a substantial source of errors and risks to patients, but one that can benefit from immediate attention through processes improvement. More commonly referred to as "handoffs," "transfers," or "sign-out" in the United States, the committee chose the term "handover" for this report because it better encompasses the goal of these pivotal moments, suggesting that they are intended as a handing over of responsibility for a patient from one healthcare provider to another and not simply a quick transcription of patient information at the end of one's time on duty.
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From page 267... ...
The next several sections discuss the role handovers play in the continuity of patient care, the impact they have on patient safety and resident education, how they are affected by the regulation of duty hours, and suggestions for redesigning handover processes to optimize patient safety and resident education. Consequences of Transfers and Communication Failure for Patient Safety Several studies, not specific to residents, highlight observed patient cases that point out the errors -- at times fatal -- caused by poor communication during handovers (Beach et al., 2003; Gandhi, 2005; Vidyarthi, 2004; Wachter, 2008; Wachter et al., 2006)
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From page 268... ...
. Impact of Duty Hour Regulations on Handovers and Continuity of Care Although fewer duty hours or appropriately placed rest periods may help to reduce fatigue in residents, they raise serious concerns for continuity of care.
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From page 269... ...
. Here in the United States, the Joint Commission has recently established a National Patient Safety Goal specific to improving handover practices (which apply to all healthcare professionals, not only to residents)
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From page 270... ...
© The Joint Commission, 2008. Reprinted with permission.
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From page 271... ...
, or outpatient and inpatient settings, but that core components would be instituted within a basic framework with consistent principles. Therefore, the basic elements that may help improve current medical handover processes presented in the following section are general suggestions.
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From page 272... ...
Although electronic systems have demonstrated improved resident performance and patient outcomes by reducing rates of adverse events and allowing residents more time to spend on direct patient care (Petersen et al., 1998; Van Eaton et al., 2005) , very few residency programs or hospitals actually employ electronic sign-out systems.
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From page 273... ...
These interns suggested improvements in handover practices to help them make more informed and accurate decisions about patient care and reduce duplicative or unnecessary work. The recommendations included a request for face-toface interactions; reviewing anticipated areas for care or troubleshooting; and having an accurate, updated, legible, written worksheet that includes standard patient content and medical information (Arora et al., 2005)
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From page 274... ...
Integrating patients more openly into the care team allows team culture to extend beyond the resident or integrated teams, adding a more personal view of the patient's perspective to the team. Patients familiar with this handover practice also suggest that hospital staff introduce themselves, use an understandable vocabulary when speaking to them, and include patients in discussions to maximize the value to patient and to promote team thinking (Simmons and Gonzalez del Rey, 2008)
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From page 275... ...
Creating a formal protocol to transfer clinical information and patient care thoroughly and accurately, in any setting, can go a long way to help prevent or intercept errors, enhance workforce communication, provide educational opportunities for residents, and possibly assist to minimize the negative effects of increased shift work. The committee concludes that whichever method or combination of methods is used to improve handovers, the key factor is that handovers be structured, while also conforming to the needs and capacity of particular departments or settings.
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From page 276... ...
. Additionally, materials on handovers could give case examples of how the type of information transferred can influence the outcomes of patient care.
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From page 277... ...
required by residents for handovers of a specific number and severity of patients, when joint bedside visits would be recommended, minimum information transfer needed for all patients, availability of supervisors at handovers, the impact of face-to-face handovers and how handovers can be opportunities for intercepting errors. Training Doctors and Error Reporting In addition to the latest, evidence-based best practices for patient care and structured handover procedures, new physicians must also learn and practice safety and quality improvement principles and methods.
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From page 278... ...
. The alert states that several surveys have found that a majority of healthcare workers have seen or experienced such behavior and one study found that "40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator" (Joint Commission, 2008, p.
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From page 279... ...
Information from error reporting and root-cause analyses of critical cases could also contribute significantly to residents' education. Since the focus of most hospital error-reporting programs has been on system-wide problems rather than on the individual, and they frequently guarantee confidentiality, they often do not note characteristics of the individual who was involved in the event, such as profession, discipline, and training status.
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From page 280... ...
Knowledge that the reported information will be used to enhance patient care is critical to motivate doctors and other caregivers to make the effort to report an incident. The perception that there is no follow-up can be a deterrent to reporting (Evans et al., 2006)
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From page 281... ...
Health information technologies include up-to-date patient-specific data in electronic medical records, clearly documented handovers from other team members, and diagnostic support systems that offer clinicians opportunities to avoid reaching premature closure on diagnoses. Information technology (IT)
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From page 282... ...
Adoption of these systems can have value to all staff on patient care teams and is not resident specific. Developing A Team culture It has been recognized that healthcare structures are complex, "characterized by competing responsibilities and an evolving perception of patient care as a collective responsibility" (Park et al., 2007, p.
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From page 283... ...
Residents will continue to strive to be independent practitioners, but given their time constraints and the content of their work, distributing workload among colleagues can help them collectively better manage their time and alleviate demands while on duty. In this way, a team dynamic lends itself to better organization, which has the potential to better sustain continuity of care among multiple health practitioners and, in turn, help improve overall patient care.
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From page 284... ...
. Targeting residents is a good way to introduce teamwork and shared accountability across these interdependent teams, which can help develop structured communication among all healthcare workers and ultimately reduce gaps or errors in patient care.
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From page 285... ...
, demonstrating that improved patient care and resident learning can both be facilitated by team structures. Other efforts incorporating interdisciplinary or multidisciplinary team rounds had very similar results of reduced LOS and improved core knowledge and team skills (Curley et al., 1998; O'Mahoney et al., 2007)
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From page 286... ...
To eliminate preventable adverse events and intercept other errors before they harm the patient, it is important to have in place an environment that is both mindful of errors and nonpunitive, as well as leaders willing to consider redesign of the institutions' systems and processes as necessary to reduce risks. The emphasis on handovers, blame-free error reporting, and teamwork does not mean that individual residents are not expected to develop a sense of loyalty or personal responsibility for individual patient care, but it helps ensure that the best information is available at all times for patient care given that a resident or any caregiver cannot be at the bedside 24 hours a day, 7 days week.
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From page 287... ...
2008. The ACGME duty hour standards: One element for promoting good learning, safe patient care and resident well-being: Data on compliance and effect.
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2001. A system of analyzing medical errors to improve GME curricula and programs.
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2006. Transfers of patient care between house staff on internal medicine wards: A national survey.
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1993. The impact of a regulation restricting medical house staff working hours on the quality of patient care.
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1998. Using a com puterized sign-out program to improve continuity of inpatient care and prevent adverse events.
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2007. Medical errors involv ing trainees: A study of closed malpractice claims from 5 insurers.
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From page 293... ...
2008. The ambulatory long-block: An Accreditation Council for Graduate Medical Education (ACGME)
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