Miscommunication, Handoffs, and Patient Presentations

Question 1

What are the two most important, preventable etiologies of medical errors in the hospital setting?

Answer 1

• Miscommunication
• Handoffs errors

Question 2

What method can be used to reduce miscommunication errors in the hospital setting?

Answer 2

Closed-loop communication

Question 3

How does closed-loop communication work (3 steps)?

Answer 3

1. Information is given →
2. The receiver repeats back the information →
3. The giver confirms the accuracy

Question 4

When performing a handoff of patient care, what are some aspects of the setting and/or format that are more conducive to a successful, safe handoff?

Answer 4

• Interactive communications
• Limited interruptions
• A process for verification
• An opportunity to review any relevant historical data

Question 5

What aspects of the environment will increase the likelihood of success in patient handoffs?

Answer 5

• Private, quiet area
• Limited distractions
• Organizational safety

Question 6

What language should be used and/or avoided in performing patient handoffs?

Answer 6

Use: standardized medical terminology

Avoid: colloquialisms; abbreviations (unless universally well-known)

Question 7

When giving a nurse or provider or physician instruction, how can one help prevent miscommunication in a quick, simple manner?

Answer 7

Use closed-loop communication

(E.g., just to make sure I stated the order clearly, would you mind repeating it back to me?)

Question 8

What mnemonic can be used to remember the format for handoffs in acute settings requiring quick communication?

Answer 8

SBAR

Situation-Background-Assessment-Recommendation

Question 9

Describe the information quickly transmitted in a handoff using the SBAR mnemonic:

Situation -

Background -

Assessment -

Recommendation -

Answer 9

Describe the information quickly transmitted in a handoff using the SBAR mnemonic:

Situation - the immediate concern and/or reason for hospitalization (“COPD exacerbation;” “foreign body inhalation;” etc.)

Background - history of illness; disease/treatment course; etc.

Assessment - immediate needs; options and expected outcomes

Recommendation - next steps

Question 10

What mnemonic can be used to remember the format for handoffs in calm, non-acute settings; e.g., the day team handing off to the night team?

Answer 10

I-PASS

Illness Severity

Patient Summary

Action List

Situation Awareness and Contingency Planning

Synthesis by receiver

Question 11

What are the components of the ‘I-PASS’ handoff format?

Answer 11

Illness Severity

Patient Summary

Action List

Situation Awareness and Contingency Planning

Synthesis by receiver

Question 12

When using the ‘I-PASS’ handoff format, what are three main options for communicating illness severity?

Answer 12

“Stable,” “watcher,” or “unstable”

Question 13

When using the ‘I-PASS’ handoff format, what should be included in a patient summary (long-ish section)?

Answer 13

1. Summary statement
2. Events leading to admission
3. Hospital course
4. Ongoing assessment
5. Plan

Question 14

When using the ‘I-PASS’ handoff format, what is included in the action list?

Answer 14

• Any to-do items
• Timeline and ownership

Question 15

When using the ‘I-PASS’ handoff format, what should be communicated in the situation awareness section?

Answer 15

• Knowledge about what’s going on
• A plan for what might happen

Question 16

When using the ‘I-PASS’ handoff format, what is included in the synthesis portion?

Answer 16

The receiver summarizes, asks questions, and restates key action items

Question 17

When utilizing a SOAP note to present a patient to an attending, what is the purpose of each section of the presentation?

Answer 17

Subjective: communicates patient’s presentation and relevant history

Objective: communicates patient’s relevant vitals, physical examination, and imaging/laboratory data

Assessment: communicates any diagnosis hypotheses and the expected clinical trajectory

Plan: communicates the hypothesis testing that will take place

Question 18

When presenting a patient, why should I not say, “the examination is normal, except for…”

Answer 18

After hearing the word ‘normal,’ most attendings shut off their brains.

Just state pertinent findings and move on; don’t editorialize or add superfluous words.

Question 19

Much of medical school was about learning how to collect patient data and present it in detail.

How should my presentations change during intern year?

Answer 19

Learn to synthesize the collected data into information that can be presented quickly and efficiently as possible.

Learn to cut out all the superfluous items and just present the findings pertinent to the case.

Question 20

When presenting my plan for a patient, in what order should I proceed?

Answer 20

1. Most serious problem
2. Next most serious problem
3. Etc.
4. Barriers to discharge