Patient Handoffs Majority Of The Medical Errors Research Paper

Length: 6 pages Sources: 5 Subject: Healthcare Type: Research Paper Paper: #67770180 Related Topics: Patient Care, Patient Safety, Medication Errors, Electronic Medical Records
Excerpt from Research Paper :

Patient Handoffs

Majority of the medical errors take place in the patient's handoffs. A shift among the doctors is a common practice. There are a number of old patients who approach around 16 different doctors in a year, while young patients who are healthy refer to normal physicians and to specialists as well (Philibert, 2008). In a hospital normally, less attention is given to the patient by his primary doctor, while the trainees and the hospitalists are more involved in that patient. Patients are rotated to different doctors with an average of fifteen times in a five day stay at the hospital. Young doctors often accept appointments of more than 300 patients in a month, in their initial training period just because of time pressure (Chen, 2009, p. 1).

Alteration that have been brought about in the patients care have increased the quality of the services that are offered to the patients by the doctors and now the rested doctors have also started with an open division (Centers for Medicare & Medicaid Services, 2010). According to recent studies, there are a number of patients who are not able to identify the names of their doctors and even most of the discharge papers do not include the tests which are pending at the time of release (Philibert, 2008). When doctors transfer their responsibilities to their colleagues, then handoffs prove to be beneficial. The preparation of handoffs requires time and endeavors of the doctors to assure the safety of their patients (Chen, 2009).

Doctor who transfers his patients to any other colleague often misses to mention a few facts in the handoff while signing it off, unintentionally. The information he might forget to mention can be related to the history of the patient or linked with the reasoning of certain antibiotic. The second doctor who receives the custody of the patient might not be much responsible (Chen, 2009). That is why handoffs are often considered as misleading and complex. An important detail regarding the patient which is missed from the handoff due to slight forgetfulness of the doctor might lead to wrong or delayed decisions in future, which may even risk the life of the patient (Salvi, Schostok, & Pritchard P.C. Law Offices, 2011, p. 1).

If proper communication takes place among the doctors then there are fewer chances of errors to occur. A change in the doctors' attitude would be more beneficial than any other new procedures or assignments. It is recommended that the hospital's management should give attention towards the proper implementation HIS (Hospital Information System) (Philibert, 2008).

A change in doctor's attitude is highly recommended. The doctors should give attention toward the handoffs, and should take care of their patients only then they would be considered as good doctors who could be relied upon (Chen, 2009, p. 1). If handoffs are well maintained, then any doctor from any other hospital can also understand the situation of the patient with the help of his medical history, previous test results, and all prescriptions which were given to him. This can prevent the doctors from prescribing the drugs which can cause allergy to the patient, and can even remind the doctors about the tests which previously gave unsatisfactory results (Philibert, 2008, p. 1)

As per the Joint Commission (2012), almost 80% of the medical errors occur because of the miscommunication which takes place due to the handoffs, which lacks information due to carelessness of the doctors. When custody is transferred from one doctor to the other often important details are missed or ignored which might lead to wrong decisions being taken in future (Chen, 2009). Inappropriate handoffs often lead to poor quality of care which is provided to the patients, because the tests which have already been performed might be re performed, leading to longer hospitalization, high degree of medical errors and extra cost that is being suffered by the patients. In the past there used to be one doctor who use to look after the patient throughout his treatment, but nowadays a patient is attended by a number of different physicians according to his health requirements (Salvi, Schostok, & Pritchard P.C. Law Offices, 2011).

Handoffs are particularly concerned with physicians and the nurses, but the patient and his


They remain connected to it from the time they first meet the doctor till the time they take the discharge form. When patient and his family are made aware of all the important details regarding the ailment then it becomes safe to transfer the custody of the patient to another doctor. The complex nature of handoffs have stressed that flawless communication of patient related matters should take place while doctors are being switched (Nixon, 2009). In this communication, there are few factors which include improved communication skills of clinicians, brief and proper accessibility of the clinical-information to the patients and their families, provider, and standardized process. Furthermore, it is necessary to develop the memories of the providers with the help of much stronger system like EHRs (Centers for Medicare and Medicaid Services, 2010).

For the advancement in the processes of hospital communication, a variety of different strategies had been refined by the hospital leaders. These strategies include the betterment of the span and the capability of hand-off communications. Furthermore, they can aid in the exchange of important information regarding the patient in both the forms; verbal and written, thus, creating a team-approach for the support of free interchanges of views and observations (Kitch et al., 2008). For a better and quick exchange of important information, the hospitals are re-developing their workflow.

Importance of Information Technology

The lack of knowledge regarding the patients' history and prescribed medication is a major issue for the practitioners. Mostly the records are kept as hard-copy (on paper) and this lead to a problem in the coordination of healthcare and the providing of the detailed information regarding the quality and health-care expenses, so that the consumers can be well informed and can easily discuss regarding their healthcare. There are numerous literatures regarding healthcare which indicates that there are many errors because of the untidy writings of medical records of patients which lead to the administration of such a drug which cause allergy in patients (Solovy, 2009, p. 29). This error can be eliminated by providing the information through a EHRs and computerized system, regarding the prescribed drugs and the patients. There is another issue present today, and that is there is a gap between least wired and most wired providers of the individual providers and healthcare industry. This Gap was developed due to the adoption of technology at diverse rates (Philibert, 2008).

According to anecdotal-reports, an ordinary American have almost 5-7 out-patient charts, at the same time and these are kept by different healthcare units and providers, such as primary-care specialists and doctors. By the passage of time these charts can be doubled or tripled. Clinicians rarely share their records with the hospital medical-records. Most of time, the physicians cannot find the patients information in the medical records (Philibert, 2008).

Today the medical records are kept without taking advantage of information technology in the prospect of vast majority of ambulatory practice-settings (Shawahna et al., 2011). According to recent studies, it is a must thing that the ambulatory healthcare introduces the electronic-prescriptions and keep an electronic medical-record.

It is an established fact that IT has proven really valuable in dealing with various aspects of work load (Decision support systems may reduce inappropriate medical tests, 2011). IT has the ability to overcome the errors occurring in the practice of ambulatory as the atmosphere of ambulatory practice is not well understood than the inpatient atmosphere. Therefore, errors are bound to happen.

It was found out through a recent Harris Interactive survey that almost 10% of sub-specialist and 15% of primary care physicians often use some kind of automated tool for management of clinical information. Some circumstantial evidence also reveals that only three-fourth of ambulatory practice settings possess some sort of settled practice management billing system (Encinosa and Bae, 2011).

The availability of online clinical information without any kind of clinical decision support may help in improvement of clinical decision making, utilization and patient outcomes undoubtedly. If doctors have access to the chart, they may not be successful in getting some relevant information out of it, even most of the times the chart is inaccessible. It has been depicted in a study that medical information accessed through computer may result in an approximate $596 on per patient for old aged patients per year (Epstein, et al. 2010). Some other studies in the outpatient have suggested that displaying test results or estimation of test results can lead to unreliable test utilization. Even, gain of access through wireless technology to certain restricted work settings of medical record such as laboratory results can prove a burden to utilization and management (Joint Commission, 2008).

Electronic Health Records

Electronic Health Records is known as EHR, it is a computerized system which…

Sources Used in Documents:


Centers for Medicare & Medicaid Services. (2010). Electronic health records overview. Retrieved from

Chen, P.W. (2009, September 3). When patient handoffs go terribly wrong. The New York Times. Retrieved from

Decision support systems may reduce inappropriate medical tests. (2011). Retrieved from / article:decision-support-systems-may-reduce-inappropriate-medical-tests-/

Encinosa, W.E., & Bae, J. (2011). Health information technology and its effects on hospital costs, outcomes, and patient safety. Inquiry, 48, 288-303. doi:10.5034/inquiryjrnl_48.04.02
Salvi, Schostok, & Pritchard P.C. Law Offices. (2011). Doctor suggests systemization to avoid medical errors during handoffs. Retrieved from / blog/2011/05/doctor-suggests-systemization-to-avoid-medical-errors-during-handoffs/

Cite this Document:

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"Patient Handoffs Majority Of The Medical Errors", 02 June 2014, Accessed.23 May. 2022,

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