Transitions in Care: Risk, Recovery, and Best Practices

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Effective communication is central to patient safety.1,2 The Joint Commission identifies failures in communication as the leading root cause of sentinel events in healthcare.3 Transitions in care, clinical “handoffs” are particularly critical for patient safety as they interrupt continuity, leaving potential gaps in communication and transfer of important information. While handoffs can be a source of error, they are also an opportunity for detection, identification, and prevention of failure.4 The work of healthcare teams requires the employment of effective handoff practices to ensure coordination and continuity of care, especially at transition points.4 Teamwork, effective communication, and formal handoff systems mitigate the vulnerabilities in transitions.1–4 Recent human factors research on the nontechnical components of care such as teamwork, collaboration, and mindfulness has contributed greatly to the literature on care transitions and patient safety. This column reviews the shared interdisciplinary responsibility present in transfers of care, with evidence-based recommendations for implementing best practices.
Clinical handoffs are defined as the mechanism for transferring information, primary responsibility, and authority for a patient.5 There are multiple influences on handoffs including communication methods (eg, face-to-face) and style, context, timing, complexity of information, and the skill of the care provider.6 Communication is significantly affected by speaking and listening skills.6 Impediments to effective communication include hierarchy, gender, ethnic background, and interprofessional differences in communication styles.6 The most significant barrier to effective communication is poor organization of the information by the sender and inattention by the receiver.6 Structured forms of communication such as the Situation-Background-Assessment-Recommendation (SBAR) is the most commonly cited and incorporated technique recommended for handoffs, although there are a number of other mnemonics. The handoff is the opportunity to clarify and ask questions and is meant to be a discussion between providers.1
In the context of handovers, both the immediate environment and organizational milieu are important considerations. Location, privacy, limited interruptions, and quiet are essential to the effective, clear transfer of information. Discussions in an environment free of distractions will enhance communication.1,2 Organizational structure and underlying values may shape professional interactions and impact care delivery.7 Timing of handoff, including workload pressure, and the amount of time allotted additionally affect quality.5 The skill and expertise of the providers involved in the handoff process are key.8 Clinical knowledge and skill development lead to increased awareness of the environment and situational factors surrounding a patient.
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