Handoffs during the nursing shift change were directly observed on two acute care wards each of a private and public hospital, for a total of 236 patient updates by 49 nurses during 14 shift changes. Data from the three wards which conducted audio-taped updates were transcribed. The transcriptions and field notes were analyzed for the existence and frequency of 21 strategies used in high reliability organizations. In addition, we iteratively categorized the interruptions, questions, and statements made during the updates. Finally, we iteratively categorized stances towards decisions communicated during the updates. Implications of the findings are discussed.
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References
1.
BayleyKBSavitzLARodriguezGGillandersWStonerS.Barriers Associated with Medication Information Handoffs. Advances in Patient Safety: From Research to Implementation. Volumes 1–4, AHRQ Publication Nos. 050021 (1–4). February 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/advances/.
2.
BrookRHAppelFAAveryCEffectiveness of inpatient follow-up care. N Engl J Med1971 Dec 30;285(27): 1509–14.
3.
CookRIRenderMLWoodsDDGaps in the continuity of care and progress on patient safety. BMJ 18 March 2000; Vol. 320, No. 7237.
4.
DvorakSRMcCoyRAVossGDContinuity of care from acute to ambulatory care setting. Am J Health-Syst Pharm1998;55:2500–04.
5.
GandhiT.K.Fumbled Handoffs: One Dropped Ball after Another. Ann Intern Med2005; 142: 352–358.
6.
GrusenmeyerC.Shared Functional Representation in Cooperative Tasks-The Example of Shift Changeover. The International Journal of Human Factors in Manufacturing, 5(2), pp 163–176, 1995.
7.
KeyesC.Coordination of care provision: The role of the 'handoff'. Int J Qual Health Care. 2000 Dec;12(6):519.
8.
KerrM. P. (2002). A qualitative study of shift handover practice and function from a socio-technical perspectiveJournal of Advanced Nursing, 37, 125–135.
9.
KostopoulouOShepherdA.Fragmentation of Care and the Potential for Human Error in Neonatal Intensive Care. Topics in Health Information Management (special edition of Human Error in Clinical Information Systems)2000; 20 (4): 78–92.
10.
MatthewsA.L.HarveyC.M.SchusterR.J.DursoF.T.Emergency Physician to Admitting Physician Handovers: An Exploratory Study. Proc. of the Human Factors and Ergonomics Society, 2002, pp. 1511–1515.
11.
NaylorMDA decade of transitional care research with vulnerable elders. J Cardiovasc Nurs2000 Apr;14(3):1–14, 88–9.
12.
PatersonJMAllegaRLImproving communication between hospital and community physicians. Feasibility study of a handwritten faxed hospital discharge summary. Discharge Summary Study Group. Can Fam Physician1999;2893–9.
13.
PattersonE.S.RothE.M.WoodsD.D.ChowR.GomesJ.O. (2004). Handoff strategies in settings with high consequences for failure: Lessons for health care operationsInternational Journal for Quality in Health Care, 16(2), 125–132.
14.
PattersonE.S.WoodsD.D. (2001). Shift changes, updates, and the on-call model in space shuttle mission controlComputer Supported Cooperative Work: The Journal of Collaborative Computing, 10(3–4), 317–346.
15.
PetersenLABrennanTAO'NeilACDoes housestaff discontinuity of care increase the risk of preventable adverse events?Ann Intern Med1994; 121: 866–872.
16.
RawalJBarnettPLloydBWUsed of structured letters to improve communication between hospital doctors and general practitioners. BMJ1993;307:1044.
17.
RothE.M.ChristianC.K.GustafsonM.SheridanT.B.DwyerK.GandhiT.K.ZinnerM.J.DierksM.M. (2004). Using field observations as a tool for discovery: Analysing cognitive and collaborative demands in the operating room. Cognition, Technology, and Work6(3), 148–157.
18.
van WalravenCLaupacisASethRDictated versus database-generated discharge summaries: A randomized clinical trial. CMAJ1999; 160(3):319–26.
19.
van WalravenCarlMamdaniMuhammadFangJimingAustinPeter CContinuity of care and patient outcomes after hospital discharge. Journal of general internal medicine: official journal of the Society for Research and Education in Primary Care Internal Medicinevol. 19, no. 6 (2004 Jun): 624–31.
