Medical Professional Publications

Optimal Hand-Off Communication Prevents Adverse Events

(From the February 2016 Issue of MedStat)

Failure to communicate remains a major cause of adverse events (AE). These errors often occur at transitions in patient care. Optimal “hand-off” communications is critical to prevent these errors. Recently, a “near miss” event was related to inadequate hand-off communication between services. A patient was admitted from a surgical clinic to a medical service. There was no communication between the physicians involved. Hence, the receiving service had no information about the patient. To prevent an AE, we recommend the following best practices:

  • Transfer of a patient to another service requires direct physician-to-physician communication via a 5P Handoff
    • Patient/Project
    • Problems
    • Pertinent Past History
    • Plan/Procedure
    • Precaution/Potential Pitfalls
  • The receiving physician needs to verbally accept the patient to their service.
  • Physicians are strongly encouraged to call through Physician Direct Connect (PDC) to be connected to another service physician for request to hand-off the patient.
  • PDC (patient placement) needs to know a patient has been accepted to a service before they can assign a bed.

If you have questions or concerns, please contact Rick McClead MD, Associate Chief Medical Officer at (614) 722-5121. 

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