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St. Petersburg, Florida

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Bob Carroll
Bob Carroll
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The Bermuda Triangle In Your Local Hospital

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I have known for some time that the most dangerous time for a patient in the hospital is often the change of shift. Over the years I have learned of so many bad events during the hand-off from one shift to another that I had begun to refer to the time period as the black hole. Now, a national commission is working on correcting the poor communications that appear to be the source of the problems.

Hospitals combat errors at the ‘hand-off’

For hospitals, the “hand-off” has long been the Bermuda Triangle of health care: 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.

Now, with growing evidence that communication breakdowns during such transfers are the single largest source of medical error, the Joint Commission on Accreditation of Health Care Organizations is requiring hospitals for the first time to establish standards for hand-off communications — and break down long-standing cultural barriers in the exchange of patient information between doctors and nurses.

The non-profit Institute for Healthcare Improvement…is working with hospitals on a communication model known as SBAR — an acronym for Situation, Background, Assessment and Recommendation — adapted from a program used to quickly brief nuclear submariners during a change in command.

“A hand-off is a precision maneuver, but in medicine it has been left to happenstance,” says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.

Bungled hand-offs range from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren’t aware of a “do not resuscitate” order, says Leora Horwitz, a specialist in internal medicine at Yale University and the West Haven, Conn., VA Hospital.

“It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine,” says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network.

I have known for some time that the most dangerous time for a patient in the hospital is often the change of shift. Over the years I have learned of so many bad events during the hand-off from one shift to another that I had begun to refer to the time period as the black hole. Now, a national commission is working on correcting the poor communications that appear to be the source of the problems.

Hospitals combat errors at the ‘hand-off’

For hospitals, the “hand-off” has long been the Bermuda Triangle of health care: 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.

Now, with growing evidence that communication breakdowns during such transfers are the single largest source of medical error, the Joint Commission on Accreditation of Health Care Organizations is requiring hospitals for the first time to establish standards for hand-off communications — and break down long-standing cultural barriers in the exchange of patient information between doctors and nurses.

The non-profit Institute for Healthcare Improvement…is working with hospitals on a communication model known as SBAR — an acronym for Situation, Background, Assessment and Recommendation — adapted from a program used to quickly brief nuclear submariners during a change in command.

“A hand-off is a precision maneuver, but in medicine it has been left to happenstance,” says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.

Bungled hand-offs range from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren’t aware of a “do not resuscitate” order, says Leora Horwitz, a specialist in internal medicine at Yale University and the West Haven, Conn., VA Hospital.

“It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine,” says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network.

When errors are casued by the longstanding culture of medicine we are truly dealing wtih a black hole or the Bermuda Triangle.