Annals of Emergency Medicine
Volume 53, Issue 6 , Pages 701-710.e4 , June 2009

Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care

Presented at the annual meeting of the Society for Academic Emergency Medicine, June 2008, Washington, DC.

  • Leora I. Horwitz, MD, MHS

      Affiliations

    • Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, CT
    • The Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
    • Corresponding Author InformationAddress for reprints: Leora Horwitz, MD, MHS, Yale–New Haven Hospital, 789 Howard Ave, New Haven, CT 06510; 203-688-5678, fax 203-688-5571
    • ,
  • Thom Meredith, MD

      Affiliations

    • Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, New Haven, CT
    • ,
  • Jeremiah D. Schuur, MD, MHS

      Affiliations

    • The Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
    • The Department of Medicine, Harvard Medical School, Boston, MA
    • ,
  • Nidhi R. Shah, MD, MPH

      Affiliations

    • Hospitalist Service, Yale–New Haven Hospital, New Haven, CT
    • ,
  • Raghavendra G. Kulkarni, MD

      Affiliations

    • Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, New Haven, CT
    • ,
  • Grace Y. Jenq, MD

      Affiliations

    • Section of Geriatrics, Department of Medicine, Yale University School of Medicine, New Haven, CT

Received 27 December 2007 ,Revised 29 April 2008 ,Accepted 5 May 2008.

References 

  1. Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2613
  2. Singh H, Thomas EJ, Petersen LA, et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030–2036
  3. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831–841
  4. Behara R, Wears RL, Perry SJ, et al. A conceptual framework for studying the safety of transitions in emergency care. In: Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: AHRQ; 2005;p. 309–321Agency for Healthcare Research and Quality
  5. Kelly R. Goings-on in a CCU: an ethnomethodological account of things that go on in a routine hand-over. Nurs Crit Care. 1999;4:85–91
  6. Kerr MP. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs. 2002;37:125–134
  7. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manag. 1999;7:29–36
  8. Sherlock C. The patient handover: a study of its form, function and efficiency. Nurs Stand. 1995;9:33–36
  9. Eisenberg EM, Murphy AG, Sutcliffe KM, et al. Communication in emergency medicine: implications for patient safety. Communication Monographs. 2005;72:390–413
  10. Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401–407
  11. Horwitz LI, Krumholz HM, Green ML, et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173–1177
  12. Beach C, Croskerry P, Shapiro M. Profiles in patient safety: emergency care transitions. Acad Emerg Med. 2003;10:364–367
  13. Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med. 2007;14:192–196
  14. Apker J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14:884–894
  15. Beach C. Lost in transition. AHRQ WebM&M [serial online] http://webmm.ahrq.gov/case.aspx?caseID=116Accessed January 20, 2007
  16. Burke CS, Salas E, Wilson-Donnelly K, et al. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care. 2004;13(suppl 1):i96–i104
  17. Bunderson JS, Sutcliffe KM. Comparing alternative conceptualizations of functional diversity in management teams: process and performance effects. Acad Manage J. 2002;45:875–893
  18. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185:1124–1131
  19. Coiera EW, Jayasuriya RA, Hardy J, et al. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176:415–418
  20. Institute of Medicine, Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999;
  21. Horwitz LI, Moin T, Wang L, et al. Mixed methods evaluation of oral sign-out practices [abstract]. J Gen Int Med. 2007;22(S1):S114
  22. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine; 1967;
  23. Fleiss JL. Statistical Methods for Rates and Proportions. 2nd ed.. New York, NY: Wiley; 1981;
  24. Dance FEX. Human Communication Theory: Original Essays. New York; NY: Holt, Rinehart & Winston; 1967;
  25. Ruesch J, Bateson G. Communication: The Social Matrix of Psychiatry. New York, NY: WW Norton & Co; 1951;
  26. Fischhoff B. Hindsight not equal to foresight: the effect of outcome knowledge on judgment under uncertainty. 1975. Qual Saf Health Care. 2003;12:304–311discussion 311-302
  27. Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;
  28. Patterson ES. Structuring flexibility: the potential good, bad and ugly in standardisation of handovers. Qual Saf Health Care. 2008;17:4–5
  29. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732
  30. Gawande A. The checklist. In: New Yorker. 2007;p. 86–95December 10
  31. Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22:1470–1474
  32. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med. 1996;11:753–755
  33. Petersen LA, Orav EJ, Teich JM, et al. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87
  34. Van Eaton EG, Horvath KD, Lober WB, 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. J Am Coll Surg. 2005;200:538–545
  35. Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257–266
  36. Aydin CE, Rice RE. Bringing social worlds together: computers as catalysts for new interactions in health care organizations. J Health Soc Behav. 1992;33:168–185
  37. Milliken FJ, Martins LL. Searching for common threads: understanding the multiple effects of diversity in organizational groups. Acad Manag Rev. 1996;21:402–433
  38. Rex JH, Turnbull JE, Allen SJ, et al. Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Jt Comm J Qual Improv. 2000;26:563–575
  39. Ursprung R, Gray JE, Edwards WH, et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care. 2005;14:284–289
  40. Shah JY, Kruglanski AW, Thompson EP. Membership has its (epistemic) rewards: need for closure effects on in-group bias. J Pers Soc Psychol. 1998;75:383–393
  41. Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg. 2007;205:778–784
  42. Kim CS, Spahlinger DA, Kin JM, et al. Lean health care: what can hospitals learn from a world-class automaker?. J Hosp Med. 2006;1:191–199
  43. Yen K, Gorelick MH. Strategies to improve flow in the pediatric emergency department. Pediatr Emerg Care. 2007;23:745–749
  44. Lardner R. Effective shift handover, etc., prepared for the United Kingdom, Health and Safety Executive, offshore Safety Division. http://www.hse.gov.uk/research/otopdf/1996/oto96003Accessed May 30, 2008
  45. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16:125–132
  46. Solberg LI, Asplin BR, Weinick RM, et al. Emergency department crowding: consensus development of potential measures. Ann Emerg Med. 2003;42:824–834
  47. Rathlev NK, Chessare J, Olshaker J, et al. Time series analysis of variables associated with daily mean emergency department length of stay. Ann Emerg Med. 2007;49:265–271
  48. Kuperman GJ, Boyle D, Jha A, et al. How promptly are inpatients treated for critical laboratory results?. J Am Med Inform Assoc. 1998;5:112–119
  49. Spaite DW, Bartholomeaux F, Guisto J, et al. Rapid process redesign in a university-based emergency department: decreasing waiting time intervals and improving patient satisfaction. Ann Emerg Med. 2002;39:168–177
  50. Moore C, Wisnivesky J, Williams S, et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646–651

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

 Supervising editor: Robert L. Wears, MD, MS

 Author contributions: LIH, JDS, NRS, RGK, and GYJ conceived the study and designed the survey. NRS, RGK, and GYJ supervised data collection. LIH was responsible for data management, including quality control. LIH, TM, and GYJ coded the data, and JDS, NRS, and RGK participated in the qualitative analysis. LIH drafted the article, and all authors contributed substantially to its revision. LIH takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Horwitz was a VA Special Fellow and was supported by the Department of Veterans Affairs during part of the time this study was conducted. Dr. Horwitz is now supported by Yale–New Haven Hospital. Neither the Department of Veterans Affairs nor Yale–New Haven Hospital had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the article.

 Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.

 Publication date: Available online June 16, 2008.

PII: S0196-0644(08)00795-6

doi: 10.1016/j.annemergmed.2008.05.007

Annals of Emergency Medicine
Volume 53, Issue 6 , Pages 701-710.e4 , June 2009

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