Communication gaps during shift changes in healthcare facilities often lead to errors that cause serious patient health events. During a shift change, healthcare providers go through handoffs that are expected to follow certain procedures. For example, a nurse should make sure that the bedside shift report for each patient under their care is complete before they change shifts.
Unfortunately, communication gaps still occur despite safeguards being put in place. Workplace distractions might cause a clinician to miss vital details in a patient’s report as they come on shift. Or, extreme fatigue and burnout could contribute to a care provider forgetting to put a patient’s details into a report.
In some cases, the healthcare program’s policies may be to blame for communication gaps. Lacking a standardized structure for communicating with incoming staff could leave room for confusion and omissions due to memory lapses. Even outdated technology could cause issues with electronic reports if information isn’t saved properly or isn’t easy to pull up at the start of a shift.
Sadly, many medical errors caused by these communication gaps can have drastic consequences for patients. Exploring how shift change communication problems can impact a person’s health can help you understand what might have happened to you or a loved one during a recent visit to a healthcare facility.
Causing Medication Discrepancies
Medication mishaps can range from mild accidental double doses of common over-the-counter types to severe life-threatening drug interactions. During shift changes, it is important for healthcare providers to be able to quickly assess whether a patient has known allergies to common medications.
Healthcare workers should also be able to see when a patient had their last dose, along with the amount. If this information isn’t clear or readily available, then it is possible for a nurse or other healthcare provider to omit a dose or double up on one. Holding handoffs at the patient’s bedside can help to ensure that the receiving clinician has time to go over all of the important information with the current one.
Practicing read-back verification strategies can also help to ensure that the receiving clinician fully understands the information being conveyed. Repeating which medications the patient had recently taken helps to prevent simple mistakes that could lead to adverse health events.
Delaying Essential Medical Interventions
A patient’s health status doesn’t patiently wait for the shift change and handover to be complete. Instead, it is possible for a person to experience worsening symptoms that haven’t reached the point of medical intervention at the time of the shift change. Failing to convey the patient’s unstable status could cause the incoming care provider to overlook the need for interventions soon after they start their shift.
A communication error could also include failing to read through critical lab results that just came in. Or, a clinician who is leaving for the day might assume that the incoming one will see them and take action. Establishing a clear handoff of responsibility that includes going over new health information is important for making sure the patient receives all of the interventions they need.
In a worst-case scenario, overlooking critical lab reports or a patient’s worsening condition could cause them to develop life-threatening symptoms. Alternatively, a lab report might reveal that a patient’s medication levels are higher than expected, which could lead to an overdose or serious side effects.
Following the best practices for communication during shift changes should include discussing any new or changing symptoms. Going over recent lab results and other reports together can also help healthcare providers collaborate on a plan for moving forward. By combining two sets of eyes, it’s less likely for essential information to be overlooked during the handoff.
Contributing to Preventable Accidents
An incomplete patient handoff can easily lead to preventable accidents that lead to new injuries or worsened conditions. For instance, failing to notify the incoming clinician that a patient has just begun experiencing dizziness or weakness could create a fall risk. The same is also true about failing to communicate about a patient’s medication side effects, causing them to feel off-balance.
Hospital-acquired infections are another common preventable health issue that develops from poor communication. For instance, care teams need to communicate with each other about details such as when a patient’s catheter or other medical device was placed, along with the time for its removal. Failing to do so could raise a patient’s risk for developing systemic infections.
A failure to communicate the need to prepare a patient for surgical procedures could also lead to missed patient decolonization. For instance, an incoming nurse may assume that a patient has already been provided with antiseptic baths to decolonize MRSA. If the exciting clinician did not perform the procedure, then this assumption could heighten the possibility of the patient developing a surgical site infection.
Although healthcare providers are human and therefore not perfect, the truth is that many medical errors are preventable. If you or a loved one recently experienced a sudden infection, preventable accident-related injury or worsened condition due to delayed care, then you might face a long journey to recovery.
Working with an experienced medical malpractice lawyer like the attorneys at Thomas Law Offices can help you identify any communication errors that might have contributed to the incident. Being able to show that a health worker’s inability to communicate correctly during a shift change could help you receive compensation that helps cover increased medical costs from extended hospital stays. You may also be eligible to receive compensation for lost work time or the need to pay an additional caregiver at home during your recovery.
While you can’t go back in time to save yourself, holding healthcare programs and clinicians responsible for their actions could also help future patients from suffering the same fate. Ensuring that all healthcare programs implement defined strategies for managing handoffs during shift changes helps to reduce incident rates in medical facilities. From using evidence-based frameworks to standardize information sharing to eliminating disruptions and distractions during handoffs, it is possible to lower medical errors during shift changes.
