practice partner
practice points from the ICRC
In its review of cases, the Inquiries, Complaints and Reports Committee identifies clinical or practice issues
that may be of educational value to the profession.
Handover of Care
Communication critical to
ensuring patient safety
A
photo: istockphoto.com
49-year-old female with
pancreatic cancer had a
complicated “whipple”
surgical resection performed
on December 29th. The surgeon, who
performed the operation, assessed the
patient the next morning and found
the patient to be stable. Later that
same day, the surgeon transferred the care of
the patient to Surgeon 2 and left for a planned
leave of absence. This second surgeon, who also
specialized in complex surgery, became the MRP.
However, Surgeon 2 did not get involved in the
patient’s care until January 3rd when he was
contacted by the general surgery team on call
over the holidays with news that the patient had
deteriorated and in need of his assistance.
A 42-year old male with gastroenteritis fell at
home and struck his head. He was admitted to
the emergency room via ambulance. The patient
was assessed by the emergency physician who
admitted the man for observation and offered
hydration and antiemetics.The emergency physician then transferred care to the internist on call
who accepted the patient six hours after he was
triaged in the emergency room. The internist was
not made aware of the significance of a potential
head injury and believed that this handover
was a simple case of gastroenteritis. At the time
of transfer of care, the internist was notified of
increasing headache and vomiting. However, she
did not assess the patient until 12 hours later,
at which point the patient was critically ill and
unresponsive.
During even a short period of illness, a patient can potentially be treated by a number
of health-care practitioners and specialists in
multiple settings. And each different transfer
of care introduces a safety risk to the patient.
Why a safety risk? Well, too often the
hand-over communication between units
and between and amongst care teams might
not include all the essential information, or
information may be misunderstood.
A recent “Patient Safety Alert” issued by the
National Health Service in England revealed
communication during handover accounted
for 33% of patient safety reports between
October 2012 and September 2013.
These gaps in communication can cause
serious breakdowns in the continuity of care,
inappropriate treatment, and potential harm
to the patient.
Issue 4, 2015 Dialogue
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2015-12-16 9:36 AM