hand-off

MaryW commented on the word hand-off

My mother endured a "hand-off" error following surgery for a nonmalignant brain tumor. Because physicians failed to order anti-seizure medication, she convulsed and entered a coma for three weeks, from which she emerged a hemiplegic with limited speech.

James B. Lieber, Killer Care: How Medical Error Became America's Third Largest Cause of Death, and What Can Be Done About It (New York: OR Books, 2015), Introduction.

My professional mentor . . .had a lung transplant at age 70. During the post-surgical hand-off, his attending physician ordered a necessary but highly toxic anti-rejection drug. A misplaced decimal point meant that my very sick colleague received ten times the intended dose. It killed him.

Id.

with shifts restricted to twenty-four hours there would be more hand-offs among doctors, sometimes with poor communications, and these situations were rife with the potential for error.

Id., ch. 1.

March 1, 2016

MaryW commented on the word hand-off

Preventable adverse events — injuries due to medical errors — are a major cause of death among Americans. Although some progress has been made in reducing certain types of adverse events, overall rates of errors remain extremely high. Failures of communication, including miscommunication during handoffs of patient care from one resident to another, are a leading cause of errors; such miscommunications contribute to two of every three “sentinel events,” the most serious events reported to the Joint Commission. The omission of critical information and the transfer of erroneous information during handoffs are common. As resident work hours have been reduced, handoffs between residents have increased in frequency.

Amy J. Starmer et al.l, "Changes in Medical Errors after Implementation of a Handoff Program, New England Journal of Medicine, vol. 371, pp. 1803-12 (2014) (footnotes omitted).

March 23, 2016