Patient Safety Strategies for Hospitalists

Kathleen Stillwell, MPA/HSA, RN, Senior Patient Safety Risk Manager

Hospitalists face liability risks based on their role as an inpatient’s attending physician, covering physician, consultant, and/or co-manager. Two common problem areas are confusion regarding the hospitalist’s role in the patient care continuum and miscommunication during the different phases of inpatient care—especially during handoffs. The following strategies can help hospitalists reduce liability risks.

Clarify Roles and Scope of Care

First, make sure that you, your group, and the hospital all agree on your job description and privileges. Explain the hospitalist’s role to the patient and family. For example, are you covering for the attending physician or serving as the attending physician? Who will coordinate care with specialists? Clarify your role with the other care providers to avoid confusion among the healthcare team regarding the specific components of a patient’s care.

Use Standardized Communication Tools and Protocols

Standardized communication tools, methods, forms, templates, checklists, and protocols such as the SBAR format (Situation, Background, Assessment, Recommendation) are helpful in managing communication between providers effectively. At a minimum, communicate the patient’s diagnosis, current condition, recent changes in condition or treatment, and any anticipated changes. Check with the hospital to find out which communication tools or protocols it uses.

Use only approved medical interpreters. Document the name of the interpreter according to facility policy. The patient’s family is the last resort for medical interpretation.

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

Be Aware of Risky Transitions

Transitions in hospital care can occur many times in the course of a patient’s treatment. Good communication between providers during patient transitions is essential. Communication breakdowns—compounded by human factors such as fatigue, distractions, and reliance on memory—are common threads noted in healthcare provider claims.

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 department, such as diagnostic testing.
• Transfer to a consultant.
• Handoff to another clinician when a clinician goes off duty or on vacation.

Structure Effective Handoffs

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:

1. What is important to communicate?
2. Who needs to know what information?
3. When should communication occur?
4. How should the information be transmitted?
5. Is there an opportunity for the receiver of the information to ask questions?
6. How can I validate that the communication was successful?

The following strategies can help decrease human errors during the handoff process:

• Employ technology whenever possible. Effective handoffs are facilitated when the electronic health record 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 will help decrease human error.
• 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.
• Actively listen 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 providers.

Manage Coverage Change

Patients should always know who is taking care of them. Servers in restaurants are typically trained in how to make the transition: The current server introduces the new server personally, and lets the patron know that the new server is now attending the table. This same technique works well with patients. 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.

• When changing coverage, let your patient know who will be taking over for you. Consider handing the patient your colleague’s business card or using the whiteboard (if one is provided in the patient’s room) so the patient is left with information on the next care provider and how to contact him or her.
• 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.
• Ask your patient to specify any issues that he or she wants communicated to the subsequent treating caregiver.
• Discuss with the patient and family how pending tests and consults and the treatment plan will be handled going forward.
• Document a recap of the care provided and outline any follow-up issues.

Standardize Provider Training

Standardize training on how to conduct successful handoffs with other providers.

• Engage the hospital staff in the training for handoff communications.
• 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 your handoff communications is essential due to today’s fragmentation of care. Any care provider that passes off the patient to another plays a key role in improving this aspect of patient safety.

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