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Patient Transfers Leading Cause Of Medical Errors

The Wall Street Journal’s health blog has highlighted action by the Joint Commission to improve patient care nationwide. According to the Joint Commission, about 80 percent of serious medical errors result from miscommunication when a patient is transferred from one caregiver to another. The Joint Commission, a healthcare accreditation and oversight organization, is working with 10 U.S. hospitals and healthcare systems to develop methods to improve patient hand-offs.

Patient hand-offs occur when a sending caregiver conveys information about a patient’s care to a receiving caregiver who is then responsible for the patient’s needs. A teaching hospital may have 4,000 hand-offs in a typical day.

One of the participating hospitals is Stanford Hospital and Clinics of Palo Alto, California. Kevin Tabb, M.D., CMO of Stanford Hospitals and Clinics explained, “Being able to identify where there are breakdowns in the hand-off process and focus on where we can improve, as well as develop targeted solutions, will improve the quality of care patients receive.”

Causes and Consequences of Ineffective Patient Hand-Offs

The participating healthcare organizations found hand-offs were problematic over 37 percent of the time. This resulted in the receiving caregiver being unable to appropriately care for the patient. Healthcare organizations provided several reasons for ineffective patient transfers. These included a lack of teamwork and respect, delayed communication, shortage of time and ineffective communication.

Examples of medical errors this type of miscommunication can lead to include: unnecessary extended hospital stays, medication errors, delays in treatment or inappropriate treatment. Other consequences include serious physical or psychological injury and wrongful death.

Solutions to Improve Patient Transfers in California

The Joint Commission is now promoting several tactics to improve hand-off effectiveness. The Joint Commission uses the acronym “SHARE” to promote the following best practices: Standardize critical content, Hardwire within your system, Allow opportunity to ask questions, Reinforce quality and measurement, and Educate and coach. Medical staff and hospitals should follow these best practices and the ideas behind them to improve patient transfers.

The healthcare organizations that completely implemented these best practices decreased their defective hand-offs by an average of 52 percent.

If you have been the victim of a serious medical error that was the result of an ineffective patient handoff or another healthcare system breakdown you should contact an experienced medical malpractice lawyer. An attorney can work to hold those responsible for your suffering accountable. The medical malpractice lawyers at Corsiglia, McMahon & Allard, L.L.P. take most cases on contingency. Call us in San Jose at (408) 289-1417.

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