Miscommunication and Hurried Handoffs Threaten Patient Safety

Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, The Doctors Company

Communication issues among providers continues to be one of the most frequently cited patient safety and risk management factors found in our closed claims analyses. As the following case illustrates, miscommunication and missed opportunities resulting from hurried handoffs can produce fatal results.

Case Example

A 57-year-old female presented at 9:11 PM to the hospital emergency department (ED) complaining of nausea, vomiting, and numbness of the left side of her face and left arm. She had anxiety, difficulty swallowing, fever, chills, severe intermittent abdominal cramps, and abrupt onset of chest pain for a few hours prior to admission. The patient, who was five feet four inches tall and weighed 192 pounds (BMI 32.95), had a blood pressure of 190/120.

The patient reported a history of hypertension, but she had stopped taking her blood pressure medication approximately six months before due to financial problems. The emergency medicine (EM) physician ordered a complete blood count, chemistry profile, cardiac enzymes, and an electrocardiogram (ECG).

After receiving antiemetic medications, the patient’s nausea improved. Although her cardiac enzymes were within normal limits, her white blood count was 12,700 per mcL (normal 4,500–11,000 per mcL), blood urea nitrogen was 27 mg/dL (normal 7–20 mg/dL), and creatinine was 2.6 mg/dL (normal 0.5–1.5 mg/dL). The ECG (read by the computer) showed sinus bradycardia, left ventricular hypertrophy, and nonspecific ST and T wave abnormality.

The EM physician diagnosed dehydration and renal failure and contacted the onsite hospitalist for admission. The hospitalist admitted the patient for observation. She ordered intravenous fluids and a 24-hour urine test for creatinine and protein. The hospitalist later noted that because the EM physician had not communicated a sense of urgency, she planned to see the patient in the morning. Neither physician ordered any medications to treat the patient’s hypertension.

At 12:30 AM, the patient arrived on the nursing unit, and the emergency nurse gave a report to the RN accepting the patient’s care. According to the RN, the emergency nurse mentioned that the hospitalist was aware of the elevated blood pressure and was going to “deal with it in the morning.”

The RN assigned to the patient was fairly new and inexperienced. The patient’s blood pressure was 180/100 upon admission to the floor. At 1:00 AM, the patient’s skin was pale, and she complained of back pain.

The RN called the hospitalist, obtained an order for Tylenol for the back pain, and administered it 30 minutes later. At that time, the patient’s blood pressure was recorded as 190/100. An hour and a half later, the RN called the hospitalist again to report that the patient continued to complain of nausea and back pain. The hospitalist ordered Percocet and Compazine. There was no documentation to indicate that the RN reported the elevated blood pressure.

The RN later stated that because the blood pressure reading was unchanged from when the patient was admitted in the ED, she did not consider reporting it because she understood that the hospitalist was already aware it was elevated. The hospitalist stated that she was not aware of the elevated blood pressure and, if she had been notified, would have seen the patient and ordered additional testing.

Forty-five minutes later, the licensed practical nurse working under the RN recorded the blood pressure as 212/162. She reported this reading to the RN.

The RN, according to hospital policy, reported the elevated blood pressure to the nursing supervisor. The supervisor later stated that she thought the RN reported the pressure as 212/106; and when she asked if the patient was symptomatic, the RN had replied “no.” The supervisor testified that she decided not to call the hospitalist and did not direct the RN to call the hospitalist because the patient’s blood pressure was not significantly different from the reading taken in the ED.

The patient continued to complain of chest tightness and back pain with no radiation. Her skin was warm and dry, and she was up to the bathroom. At 6:30 AM, the RN noted that the patient was sitting quietly in the bedside chair with unlabored respirations and normal skin color.

While taking another patient to surgery at 6:55 AM, the RN passed the patient’s door and noted the patient lying on the floor. Her color was dusky, and she was unresponsive. Although a code was called and resuscitation attempted, it was unsuccessful and the patient was pronounced dead at 7:21 AM.

The autopsy listed the cause of death as cardiac tamponade caused by acute aortic dissection that had developed over hours. The autopsy also noted that aortic dissection was caused by “years of hypertensive cardiovascular disease.” The dissection extended from the root of the aorta to the iliac arteries—the full length of the aorta.

What Went Wrong

Critical lapses in communication among care providers were the major factors in this case:

  • The EM physician and the hospitalist gave widely divergent accounts of what was communicated during their physician-to-physician handoff.
  • The emergency nurse did not clearly communicate with the RN about the hospitalist’s knowledge of the elevated blood pressure.
  • The emergency nurse and the RN did not communicate any concerns about the lack of blood pressure treatment.
  • The nursing supervisor and the RN were not clear in their communications on the blood pressure readings or the need to contact the hospitalist.
  • The RN did not provide complete communication about the patient’s condition when calling the hospitalist about the patient’s pain. The hospitalist claimed she was not informed by the RN of the extremely elevated blood pressure readings.

Patient Safety Strategies

Implementing the following patient safety strategies can help improve communication among providers and reduce patient harm:

  • Utilize a structured communication protocol when exchanging information with another caregiver, especially during a handoff of patient care. Evidence-based practice requires communicating essential information—regardless of whether it is communicated via an electronic template or a written or verbal exchange—in a consistent way to help decrease human error. Structured format examples include:
    • SBAR (Situation, Background, Assessment, and Recommendation).
    • I-PASS (Illness, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver).
  • Ensure that any anticipated patient care problems, considered diagnoses, pending significant laboratory results, anticipated procedures, and pending consultations are included in the standardized communication.
  • Employ face-to-face or active person-to-person communication when feasible so that both parties have the opportunity to ask and respond to questions.
  • Communicate in an environment as free of distractions and interruptions as possible. Designate and use a quiet area away from busy nursing stations, background noise, televisions, etc.
  • Maintain awareness of the information being transferred—actively listen and take notes.
  • Ask for critical information and verbal or telephone orders to be read or repeated back.
  • Establish a culture of patient safety in which staff is empowered to speak up, ask questions, and advocate for the patient. Staff should be comfortable using advocacy and assertion skills and the chain of command until all concerns are addressed.

For additional guidance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 3. Communication

Rosenbluth G, Destino LA, Starmer AJ, Landrigan CP, Spector ND, Sectish TC, I-PASS Campaign Committee. I-PASS handoff program: use of a campaign to effect transformational change. Pediatr Quality Safety. 2018;3(4):p e088. journals.lww.com/pqs/Fulltext/2018/07000/I_PASS_Handoff_Program__Use_of_a_Campaign_to.3.aspx

The Joint Commission. Sentinel Event Alert 58: Inadequate hand-off communication. jointcommission.org/en/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/

Ward B. How to improve patient handoffs. HealthLeaders. March 13, 2020. healthleadersmedia.com/nursing/how-improve-patient-handoffs

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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