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Patient Safety pp 35–51Cite as

Handoff and Care Transitions

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Abstract

In the current landscape of decentralized and increasingly specialized and fragmented healthcare services, managing the quality of the handoff process is critical in ensuring continuity of patient care. This chapter explores some of the challenges with patient handoff through two case studies. In the first case, inadequate handoff led to a maternal death by postpartum hemorrhage; in the second, communication breakdown resulted in a death by overdose of analgesia. A chain of communication failures, combined with a confluence of human and system errors, cumulatively cascaded into these unfortunate events. Key problems contributing to poor patient handoff included communication failures caused by diversity of expertise and expectations and unavailability of information after transition of care. Communication problems were further exacerbated by workload and resource constraints, and the absence of guidelines and well-defined inter-team lines of responsibility. Strategies to improve handoff should include training individual care providers, as well as tackling the underlying systemic issues. These include standardizing critical clinical processes and inter-team lines of responsibility, instituting induction program to ensure new staff members are familiar with the relevant protocols, providing adequate supervision for junior staff members, better coordination of available resources, and improving information availability through information technology.

“The single biggest problem in communication is the illusion it has taken place.”

George Bernard Shaw

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Authors and Affiliations

  1. Centre for Health Informatics, University of New South Wales, Sydney, NSW, 2052, Australia

    Mei-Sing Ong Ph.D. & Enrico Coiera M.B.B.S., Ph.D., F.A.C.M.I.

Authors
  1. Mei-Sing Ong Ph.D.
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  2. Enrico Coiera M.B.B.S., Ph.D., F.A.C.M.I.
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Correspondence to Mei-Sing Ong Ph.D. .

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Editors and Affiliations

  1. Norwegian American Hospital, Chicago, Illinois, USA

    Abha Agrawal

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Ong, MS., Coiera, E. (2014). Handoff and Care Transitions. In: Agrawal, A. (eds) Patient Safety. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-7419-7_3

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  • DOI: https://doi.org/10.1007/978-1-4614-7419-7_3

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-7418-0

  • Online ISBN: 978-1-4614-7419-7

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