SALT LAKE CITY — Ten U.S. hospitals, including LDS Hospital in Salt Lake City, are designing ways to improve "handoffs" when caregivers transfer critical patient information to each other, because any details that fall through the cracks can jeopardize a patient's care.
The Joint Commission, which accredits and certifies 18,000 health care organizations across the country, estimates 80 percent of serious medical errors involve miscommunication between caregivers when responsibility for patients is handed off from one caregiver to another. It says defective handoffs can lead to delays in treatment, inappropriate treatment, increased length of stay in the hospital and, in extreme cases, serious physical or psychological injury and death.
At LDS Hospital, whether patient Stan Halversen's condition is simple or complex, registered nurse Lynn Colgren can omit no details when passing information to the next nurse on duty. In that exchange, the nurse leaving is the "giver," while the next nurse is the "receiver."
"Any piece of that information that isn't provided could cause injury or a delay in care," said LDS Hospital administrator Todd Neubert.
A single patient in a hospital room, say on a three-day stay, could see as many as 25 different health care workers in shift changes, including nurses, therapists and physicians.
Dr. Scott Hansen, hospital medical director, said, "The opportunity here is to weld all of that information together so whoever is making the next treatment decision has the benefit of all of that information."
This "handoff," as it's called, is critical and needs not just computer data alone, but a one-on-one, face-to-face verbal exchange.
Among 10 U.S. hospitals the Joint Commission has asked to work together to improve these exchanges, LDS Hospital is among five actually piloting techniques that could become a standard for the country. All health care workers at the Salt Lake hospital are now using a form to make sure nothing is omitted.
"It's built-in redundancy," Colgren said. "I can't forget. I can't forget. If my boxes aren't filled up, if there is something I don't know, I will ask and get an answer. And sometimes, the answer is 'I don't know,' but at least I know that it has been addressed."
So far, LDS Hospital's protocol has reduced communication problems by 50 percent.
The other nine medical organizations include: the Mayo Clinic Saint Marys Hospital in Rochester, Minn.; Johns Hopkins Hospital in Baltimore, Md.; Massachusetts General Hospital in Boston; Stanford University Hospital and Clinics in Palo Alto, Calif.; Lutheran Medical Center in Wheat Ridge, Colo.; Fairview Health Services in Minneapolis, Minn.; Kaiser Permanente Sunnyside Medical Center in Clackamas, Ore.; New York Presbyterian Hospital in New York, N.Y.; and Alexandra Cohen Children's Medical Center in New Hyde Park, N.Y.
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