Abstract
ObjectiveThe risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors.Materials and MethodsTwo physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression.ResultsWe identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2–90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%–29%).ConclusionClinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.
Highlights
AND SIGNIFICANCEHandoffs are formal transitions in responsibility and information between providers caring for a patient provided verbally, in writing, or both
We identified all patients who had been admitted to the pediatric intensive care unit (ICU) for at least 24 hours at Children’s Hospital of Philadelphia and were subsequently transferred to medical wards between January 1, 2017 and December 31, 2017
At least 1 clinically meaningful discrepancy was identified between the transfer note and handoff document in 14 transfers (28%), and at least 2 clinically meaningful discrepancies were present in 7 transfers (14%)
Summary
AND SIGNIFICANCEHandoffs are formal transitions in responsibility and information between providers caring for a patient provided verbally, in writing, or both. JAMIA Open, 2019, Vol 2, No 3 by miscommunications during handoffs, which can be compounded by inefficient documentation systems.[1,2] In a series of 197 perioperative safety incidents, inadequate documentation was identified as the most common cause of communication breakdown.[3] accurate structured handoff documents that support verbal communications are associated with improved outcomes.[4,5,6,7] Despite the importance of accurate documentation for communication, handoffs often contain discordant information when compared to other parts of the medical record for the same patient at the same time.[8,9,10] The architecture and communication goals of the care plan in the handoff differ from those in clinician notes, with handoff documents generally focused solely on provider–provider communication where transfer notes frequently contain additional information for regulatory purposes Providers must update these documents independently, which is time consuming, and may be inefficient and error prone. Frequent updates of the care plan across multiple documents is likely to lead to lower quality handoffs as well as discrepancies—factual inconsistencies in the patient’s care plan across documents.[8,11,12,13] While information seeking patterns of individual providers or teams may vary, the mere existence of discrepant documents increases the risk of misinterpretation that can lead to uncertainty and subsequent error.[2]
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