Maurice Bernstein, M.D.
Here is a realistic scenario as written in the U.S. government’s Agency for Healthcare Research and Quality “Web M&M” website which could occur in any teaching or even in non-teaching hospital with hospitalists on duty.
An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of dofetilide (an antiarrhythmic medication) and placement of a permanent pacemaker.
The patient underwent the pacemaker placement via the left subclavian vein at 2:30 PM. A routine postoperative single view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 PM, the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% percent to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP) non-housestaff service; however, the on-call intern provides coverage for patients after the NPs leave for the day. The intern, who had never met the patient before, examined him and found him already feeling better and with improved oxygenation with the supplemental oxygen. The nurse suggested a stat x-ray be done in light of the recent surgery. The intern concurred, and the portable x-ray was done within 30 minutes. About an hour later, the nurse wondered about the x-ray and asked the covering intern if he had seen it. The covering intern stated that he was signing out the x-ray to the night float resident, who was coming on duty at 8:00 PM.
Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10:00 PM, the nurse still hadn’t heard anything about the x-ray so he met with the night float resident. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse if there was any problem. Finally at midnight, the nurse signed out to night shift, mentioning the patient’s symptoms and noting that the night float had not called with any bad news. The next morning, the radiologist read the x-ray performed at 4:00 PM and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 PM, nearly 23 hours after the x-ray was performed. Luckily, the patient suffered no long-lasting harm from the delay.
The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately postoperatively rather than the chest x-ray done at 4:00 PM, and therefore did not see the film with the large pneumothorax.
The ethical issue is to preserve patient beneficence and to avoid patient harm. Although the Joint Commission—the organization in the United States charged, through scrutiny of practices to maintain patient safety in hospitals receiving federal payment—has mandated structured signout systems, it is still the personal professional duty of each healthcare provider to make those systems work. The systems themselves involve both written and verbal forms of communication and with regard to the verbal communication, the opportunity for both parties to ask and answer questions is considered important.
There is the problem with systems described on paper: how to convert words into effective actions. This hoped for reaction is limited, I think, by a virtual natural conflict of interests within each professional participant in the care of a patient. One interest is physical and mental comfort. Interns and resident physicians working long hours without adequate rest naturally experience fatigue and opportunity to leave work becomes a specific goal. Then there is the natural conflict between the physician’s work and personal life. Beyond these conflicts is a hidden but perhaps unfounded feeling or assurance regarding the capacity or intentions of the upcoming physician toward the attentive, understanding and thus constructive continuity of the patient’s care. That is why, I think, direct communication between doctors is essential and, of course together with the nursing staff. And then, there is the patient. I would think that another participant in the “hand-off” should be, if possible, the patients themselves. They should be introduced to the “new team” and not simply be the “stable post-pacemaker placement patient in Room 231”, an object to be discussed but otherwise not participating.
It is now understood that the action of “hand-off” from one patient care team to another is a critical part of the care of patients in terms of potentially creating medical errors and thus adding to the other errors that can occur in medicine and surgery. Patients may assume that these changes carry no risk. I think patients and their families should be made aware of the need, and patients—within their capacity—be a participant in this transition just as they are asked to monitor their medication or tests performed on them. Hopefully with all actively participating, both beneficence and non-maleficence will be the ethical result of this common hospital action, the “hand-off”.