Patient Safety Strategies for Hospitalists

Physicians and advanced practice clinicians (APCs) providing hospital inpatient care (hospitalists) face liability risks due to their diverse roles as a patient’s attending, covering, consulting, supervising, and/or comanaging practitioner. Two common problems arise: (1) confusion regarding the hospitalist’s responsibilities in the patient care continuum, and (2) miscommunication during different phases of inpatient care, especially during handoffs. The following strategies can help hospitalists reduce liability risks.

Clarify Roles and Scope of Care

First, ensure that you, your group, and the hospital all agree on your job description and privileges. Formalize these expectations in writing and review them during the onboarding process.

Explain your role as hospitalist to the patient and family. For example, are you covering for the attending clinician or serving as the attending clinician? Who will coordinate care with specialists? Allow the patient and family time to ask questions.

To avoid confusion among the healthcare team, clarify your role with the other care practitioners regarding the specific components of a patient’s care plan. Participate in team briefs on the patient’s condition, treatment, and team member responsibilities.

Promote Diagnostic Safety

Enhance diagnostic safety by implementing the following strategies to support timely, accurate diagnoses: 

• Explicitly identify and communicate the differential diagnosis.
• Reassess the working diagnosis when the patient’s clinical course does not follow expectations.
• Establish reliable processes for tracking pending diagnostic tests and reconciling results received.
• Clearly assign responsibility for reviewing results and acting on abnormal findings.
• Encourage escalation or consultation from other multidisciplinary team members when uncertainty persists.
• Engage patients and families in the diagnostic process by inviting their observations and questions, explaining any diagnostic uncertainties, and providing clear follow-up and escalation instructions.
• Encourage organizational learning from diagnostic safety events and near misses with reporting, multidisciplinary review, shared lessons learned, and corrective actions to prevent recurrence.
• Document the clinical reasoning supporting the working diagnosis, significant diagnostic uncertainty, information considered, consultations obtained, and the plan for follow-up. Clear, timely documentation supports continuity of care and helps subsequent clinicians understand the diagnostic reasoning. Documentation also strengthens credibility when you need to explain or defend your care.

Use Standardized Communication Tools and Protocols

Use an organizationally approved structured handoff method. For example, the SBAR format (Situation, Background, Assessment, and Recommendation) supports concise clinical communication, and I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver) provides a structured framework specifically designed for transfers of patient information and responsibility.  Effective handoffs should allow questions, clarify contingency plans and outstanding tasks, and include confirmation by the receiving clinician.

Use the hospital-approved interpreter services when communicating with a patient who does not speak English and document it in the medical record. Use only qualified medical interpreters in accordance with organizational policy and applicable federal and state guidelines. Avoid using unqualified individuals, including family members.

Checklists can be helpful in obtaining basic yet vital patient information from either the patient or the primary care practitioner. Find out the patient’s code status, current medical status, preferences, medications, testing (completed, pending, and planned), and any new diagnosis so that you have all the information necessary to effectively manage the patient’s care.

Be Aware of Risky Transitions

Transitions in hospital care can occur many times in the course of a patient’s treatment. Good communication among practitioners during patient transitions is essential. Malpractice claims commonly identify communication breakdowns, compounded by human factors such as fatigue, distractions, and reliance on memory.

Hospitalized patients are most vulnerable to communication breakdowns during the following transitions:

• Admission to and discharge from the hospital.
• Transfer between hospital units or to a different department, such as diagnostic testing.
• Transfer to a consultant.
• Handoff to another clinician when a clinician goes off duty or on vacation.

Human errors during care transitions are multiplied when workload, hour restrictions, or other factors increase the number of handoffs. Standardizing the handoff process has been shown to lower rates of near-miss events and adverse outcomes.

Use the following questions to organize handoff communications:

• What information is important to communicate?
• Who needs to know what information?
• When should communication occur?
• How should the information be transmitted?
• Will the person receiving the information have an opportunity to ask questions?
• How can I validate that communication was successful?

These strategies can help decrease human errors during the handoff process:

• Use EHR-integrated handoff tools when available to improve accessibility and consistency of essential information. Effective handoffs are facilitated when the EHR is linked automatically to handoff tools and includes demographic data, problem lists, code status, medications, allergies, consultants, and historical and social information.
• Implement a structured handoff protocol. Communicating required information in a consistent way helps decrease human error.
• Include direct communication and confirmation that the receiving clinician understands and accepts responsibility for high-risk transitions.
• Communicate any anticipated patient care problems, including pending laboratory results, procedures, or consultations.
• Conduct face-to-face handoff communications in areas that are free of interruptions and provide an opportunity to ask questions and clarify care needs.
• Listen actively and take notes. If possible, find a quiet area for the handoff.
• Include multidisciplinary team members, the patient, and family members as needed. Do not rely on the patient or family members to communicate vital information to other practitioners.

Manage Coverage Change

Patients should always know who is taking care of them. During coverage changes, a hospitalized patient may be overwhelmed when a new caregiver comes into the room. Without proper introductions and good handoffs, the patient can easily become confused—which puts you at risk. Follow these strategies for managing coverage changes:

• Introduce yourself by name, and use the whiteboard, if available. Provide the patient with the name of and information about the hospitalist who will be available after your shift ends. Explain how to contact the on-duty hospitalist.
• Use a transitions or handoff checklist to ensure that all information is included. This type of tool allows you to rely less on your memory.
• Identify any issues that the patient feels should be communicated to the subsequent treating hospitalist.
• Discuss with the patient and family how pending tests, consults, and the treatment plan will be handled going forward.
• Document a recap of the care provided and outline any follow-up issues.

Standardize Training

These strategies can help you standardize training on how to conduct successful handoffs with other practitioners:

• Engage the hospital staff in the training for handoff communications using a standardized communication tool.
• Identify champions in the handoff process and provide positive reinforcement when handoffs follow established standardized procedures.
• Monitor the success of interventions to improve handoff communications.
• Use lessons learned to facilitate continuous improvement in the handoff process.

Understanding where and how gaps occur in handoff communications is essential to supporting quality and continuity of care. Every practitioner who passes care of the patient to another plays a key role in improving this aspect of patient safety.

For assistance, contact Patient Safety and Risk Management at (800) 421-2368 or by email.