When Poor Handoffs Cause Patients to Suffer

Patient in hospital bed is being handed off to a new medical teamA stroke.

A leg that was broken during high school football practice.

A baby about to be born…and it might be twins.

The reasons why people come to stay at a hospital are as varied as the patients themselves. But all patients arrive trusting they will receive good medical care. And while most patients do receive good treatment, sometimes the health of a patient is made worse due to poor medical care. All too often, poor patient handoff is the cause of deficient care.

Understanding Patient Handoffs

Because no doctor or nurse can stay in the hospital around the clock, patients end up being cared for by several different providers during their hospitalization. A patient may be seen by different physicians throughout the day. Generally, a patient will have a day nurse and a different night nurse due to shift changes, and other support personnel—nursing assistants, orderlies, and other professional—will change too. When shifts change, medical information about patients is transferred between the providers. This passing of patient care and information from one caregiver to another is known as patient handoff.

The handoff process can involve any of the following scenarios:

  • Handing off a patient from one doctor to another.
  • Handing off a patient from one nurse to another.
  • Handing off a patient from an outpatient setting to a hospital.
  • Handing off a patient from a hospital to nursing home.
  • Handing off a patient from a hospital to a primary care provider.

Risks With Patient Handoffs

Unfortunately, when patients are handed off to another party for care, there is an increased chance for a mishap to occur. That is because something can go wrong along the way. Just as in the childhood game Telephone, one person may hear something different or critical information can get overlooked when information is passed from person to person.

Data reported by the American Medical Association indicates that when patients are handed off from one party to another, there is an increase in adverse events. These can be anything from a doctor neglecting to provide critical information about a patient to a nurse overlooking a change in patient medication.

In an editorial published in JAMA, the Journal of the American Medical Association, Vineet M. Arora, M.D., pointed out that, “Given well-documented content omissions during handoffs, it is plausible that poor information exchanged during service change contributed to increased in-hospital mortality.” When information isn’t passed on during the service change, the new medical team may not have the right information to care for the patient. Sadly, some patients suffer serious health consequences—and some even die—as a result of poor handoffs.

Errors That Occur During the Handoff Process

The potential for something to go wrong when patients are handed off to other medical professionals is very concerning, to say the least. This is because errors are often made in which vital information could slip through the cracks and adversely affect a patient’s care.

The most common error made during a patient handoff is poor communication. Whether information is left out or miscommunicated during a shift change, bad communication is often the cause of adverse outcomes and malpractice claims.

Some other errors that medical professionals make during patient handoffs include failing to have a face-to-face conversations; instead, patient charts are often quickly passed to the next person on duty. While critical patient information should be in writing, verbal communication should also accompany the written log and the next team should read back the information to ensure the information is understood.

Unfortunately, patient handoffs often go wrong due to distractions, poor processes, lack of communications, and overworked and tired staff. When handoffs aren’t done correctly, patients can suffer from lost information, gaps in coverage, and critical information that falls through the cracks.

If your or a loved one has suffered adverse health effects as a result of negligence during the handoff process, you may have rights to a medical malpractice claim. To get your questions answered and to learn more about your rights, call our law firm for a free consultation or order a free copy of our book, Virginia Medical Negligence: What You Need to Know About Medical Malpractice in Virginia.