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Web Tool Reduced Medical Missteps During Hospital-Shift Changes: Study

Doctor in hospital using a digital tablet

It’s 4 p.m., and if you’re a hospital patient, that could be one of the most critical times of the day. Your doctor’s shift just ended, and someone new will take over your care. How these professionals communicate could have major repercussions for your recovery.

Those shift changes, also known as handoffs, are prime opportunities for key information about a patient’s condition to get lost in the shuffle. It’s essential that these relevant points are not only captured, but also effectively conveyed between hospital staff.

All too often, that doesn’t happen. But a research letter published Monday in JAMA Internal Medicine suggests hospitals can avoid such missteps by using technology to improve communication among the doctors, nurses and other health care providers at that vital point in care.

“This shows that [an electronic patient record] can help mitigate medical error,” said Dr. Stephanie Mueller, the study’s main author and an associate physician in primary care and general internal medicine at Brigham and Women’s Hospital.

Researchers analyzed the effect of a web-based tool that uses patient medical records to enhance communication during the patient handoff. It scans a patient’s electronic medical record for the information that doctors and other health workers need to know most. Then it automatically pulls that information into a separate page that’s been designed to highlight those essential details.

To evaluate the tool, the researchers surveyed residents at the end of their shifts who worked “nightfloat” — midnight to 7 a.m. — and “twilight” — 4 p.m. to 12 a.m. They checked for possible medical errors, and then rated those errors in terms of how avoidable they were. The survey started in November 2012 in advance of the tool’s February 2013 introduction, and then compared the level of error that took place before the tool was being used with those that occurred in the year that followed. Overall, the survey examined more than 5,000 patient cases.

The result: The number of medical mistakes was cut in half the year after the hospital introduced the software tool and taught employees how to use it. There were 77 errors identified between November 2012 and February 2013, compared with 45 in the following year.

As hospitals become more shift-driven because of increased attention to regulating physician work hours, these figures take on added importance. In the past, residents often worked 24-hour shifts. But safety advocates worried such a system could mean sleep-deprived doctors, who in turn would make more errors while treating patients. In fact, reducing hours has increased the number of patient handoffs, meaning there are more opportunities for information to get lost and for mistakes to be made.

The researchers argued their findings offer a path forward.

Brigham and Women’s built its tool in-house and has integrated it into the hospital’s commercially produced electronic health record.

This tool is unique to Brigham and Women’s, but it offers a strategy that other hospitals and health facilities could adopt, said Robert Wachter, interim chair at the University of California San Francisco’s Department of Medicine, and an expert in patient safety. Wachter co-authored a commentary published alongside the study.

“As hospital care is increasingly shift based, a clear and efficient handoff process is vital,” according to the commentary. “[This] study … shows how web-based handoff tools may improve hospital workflow and patient safety, but only if they are carefully built and integrated into existing systems.”

And that requires efforts by both the hospital and the vendors who develop and sell medical records systems to health facilities.

“This can be used as a model for what other health care institutions can do. … It gives a really good argument for what can be done,” said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. He was not involved in the study.

That said, any reduction in medical errors that resulted after the web-based handoff tool was put to use should not be viewed in isolation. Brigham and Women’s also introduced an educational component that accompanied the technology’s introduction. It emphasized how health professionals should talk to each other, to make sure the computer-based information is actually conveyed, and it focused on how to navigate the computer system. Plus, Mueller noted, health care is moving culturally toward emphasizing better communication, especially at shift changes. Those all could have had an impact, too.

But those threads are more entwined  than they may appear, she said. Any hospital that turns to technology needs to properly teach staff how to use it and highlight why it’s important.

“They’re all merged,” she said. “You’re not going to throw a tool in someone’s lap and say, ‘Here. Use this, and good luck.’”

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