Surgeon Information Transfer and Communication: Factors Affecting Quality and Efficiency of Inpatient Care

Objective:To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors. Summary Background Data:Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons. Methods:Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP. Results:A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering. Conclusions:Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

[1]  S. Saint,et al.  Fumbled Handoffs: One Dropped Ball after Another Improving Patient Care , 2005 .

[2]  J. Creswell.  Qualitative inquiry and research design: choosing among five traditions. , 1998 .

[3]  R. Reznick,et al.  Communication failures in the operating room: an observational classification of recurrent types and effects , 2004, Quality and Safety in Health Care.

[4]  Karl E. Weick,et al.  Puzzles in Organizational Learning: An Exercise in Disciplined Imagination , 2002 .

[5]  William B Lober,et al.  Organizing the transfer of patient care information: the development of a computerized resident sign-out system. , 2004, Surgery.

[6]  T. Brennan,et al.  Does Housestaff Discontinuity of Care Increase the Risk for Preventable Adverse Events? , 1994, Annals of Internal Medicine.

[7]  B. Hanusa,et al.  Expectations of Groups Versus Pairs of Attendings and Residents About Phone Communications and Bedside Evaluation of Hospitalized Patients , 2005, Teaching and learning in medicine.

[8]  E. Coiera.  When conversation is better than computation. , 2000, Journal of the American Medical Informatics Association : JAMIA.

[9]  William B Lober,et al.  A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. , 2005, Journal of the American College of Surgeons.

[10]  K. Sutcliffe,et al.  Communication Failures: An Insidious Contributor to Medical Mishaps , 2004, Academic medicine : journal of the Association of American Medical Colleges.

[11]  D. Bates,et al.  Adverse drug events occurring following hospital discharge , 2005, Journal of General Internal Medicine.

[12]  C. Pellegrini,et al.  Professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. , 2005, Archives of surgery.

[13]  D. Bates,et al.  The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital , 2003, Annals of Internal Medicine.

[14]  S D Small,et al.  Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. , 1995, JAMA.

[15]  K. Shojania,et al.  National Patient Safety Goals. , 2006, Bulletin of the American College of Surgeons.

[16]  José Orlando Gomes,et al.  Handoff strategies in settings with high consequences for failure: lessons for health care operations. , 2004, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[17]  N. Laird,et al.  Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention , 1995 .

[18]  Y. Donchin,et al.  A look into the nature and causes of human errors in the intensive care unit , 2022 .