Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications

Abstract

Background: Limits on resident hours increase the frequency of patient hand-offs and may contribute to information transfer problems that contribute to adverse outcomes. This study analysed attributes that affect hand-off accuracy, including use of data summaries and end-of-shift transfer strategies from high-reliability organisations.

Method: Mixed-method study combining qualitative interviews and surveys of residents in internal medicine, surgery, paediatrics and ob-gynaecology.

Findings: Strategies in resident hand-offs mirrored the intent of end-off-shift transfers in high-reliability organisations, but approaches differed, reflecting the fluid nature of residents’ work and focusing on multiple patients with differing needs. Clinical skills were relevant to hand-off quality for both participants. Cross-coverage, more common duty hour limits, had a negative effect on hand-off accuracy. It significantly increased the likelihood of unplanned changes in care and errors attributed to the hand-off. For surgery residents, asynchronous hand-offs without true interactions increased. Data summaries contributed to efficiency, but were associated with greater incidence of surprises and errors, even when they did not replace verbal hand-offs. Third parties, particularly nursing, functioned as redundant systems that prevented or trapped many hand-off errors.

Conclusions: Hand-offs depended on residents’ clinical skills, suggesting a need for education and supervision of junior residents’ transfers. Research is needed to explore how to conduct effective hand-offs under shortened duty periods. This should assess how transfer strategies and data summaries could enhance efficiency and effectiveness, and how they could substitute when a verbal interactive hand-off is not feasible.