Patient safety/original research
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.
https://doi.org/10.1016/j.annemergmed.2008.05.007Get rights and content

Study objective

We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers.

Methods

We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques.

Results

Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Conclusion

The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.

Introduction

Transfers of care among providers have been identified as a major source of medical error,1, 2, 3 yet the contribution of transfers to error remains unclear. To reduce errors, a more complete understanding of the processes involved in transferring patient care is needed. Transferring a patient from one care provider to another requires, at the minimum, communication of clinical information. However, a care transfer is much more than 1-way communication. A well-conducted transfer results in seamless continuation of care and is transparent to participating physicians, patients, and staff. Transfers also play an important role in teaching, promotion of team cohesion, emotional support, socialization, maintenance of social order, and error detection.4, 5, 6, 7, 8, 9

Most research on hospital transfers has focused on transfers within a specialty, such as resident-to-resident end-of-shift sign-out.10, 11, 12, 13 The transfer from emergency department (ED) to admitting physicians is little studied,4, 9, 12, 13, 14, 15 yet there are several theoretical reasons it may be of particularly high risk. This transfer must span changes in 3 domains—provider, department, and physical location—which may not occur simultaneously. Cultural, linguistic, and social differences between emergency and internal medicine physicians may increase potential for conflict or misunderstanding.16, 17 Often, uncertainty about diagnosis and treatment is high, yet this uncertainty may not be appreciated because of clinical inertia, cognitive biases, face-saving concerns, or a need to “prove” the patient requires admission.4, 9, 18 Results of tests and studies are frequently still pending, creating opportunities for missed follow-up. ED-floor transfers take place in a setting that can be chaotic, crowded, and rife with distractions.19 Finally, the ED-floor transfer occurs early in the hospital course, when patients may be least stable and thus most vulnerable to effects of failed transfers.

A better understanding of failed transfers may help to improve patient safety during this critical point of hospitalization. Accordingly, we aimed to identify vulnerabilities in the ED-floor transfer process through qualitative analysis of failures reported by emergency and internal medicine physicians.

Section snippets

Study Design

We designed a cross-sectional survey study that was pilot tested for clarity and content by chief residents in emergency medicine and internal medicine (see Appendix E1 and E2, available online at http://www.annemergmed.com). Self-administered, anonymous questionnaires were sent by e-mail and distributed at conferences 3 times in March 2007. A lottery for one of 3 $50 Amazon.com gift certificates was a financial incentive for participation. The Human Investigation Committee approved the study

Characteristics of Study Subjects

We received a total of 139 of 264 responses (53%). These included responses from 39 of 60 ED house staff and physician assistants (65%), 21 of 37 hospitalists (57%), and 79 of 167 internal medicine house staff (47%).

Main Results

Of the 139 respondents, 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after the ED-floor transfer (5 ED, 8 hospitalists, 27 internal medicine house staff). These 40 respondents described 36 specific errors, which were evenly divided among

Limitations

This study has several limitations. First, we did not interview participants in person, review patient records, or observe sign-outs directly. Consequently, we could not verify or obtain further elaboration on reported errors, nor could we obtain the emergency medicine perspective on the perceived errors. Hindsight and recall biases likely led to oversimplification of preceding events and possible misattribution of errors to the transfer process.26 Second, this was a single-institution study

Discussion

This survey of emergency and internal medicine physicians identified numerous vulnerabilities in the transfer of patients from the ED to internal medicine, including flaws in communication, environment, patient flow, information technology, and assignment of responsibility. These vulnerabilities contributed to errors of diagnosis, treatment, and disposition at all points of ED care, starting from the dialogue between patients and emergency physicians and ending in the final transfer of

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    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.

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