Background: The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm. 

Methods: In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers. 

Results: Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (κ 0.78–1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems. 

Conclusion: Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

https://qualitysafety.bmj.com/content/qhc/14/6/401.full.pdf

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Healthcare processes require the cooperation of different organizational units and medical disciplines. In such an environment optimal process support becomes crucial. Though healthcare processes frequently change, and therefore the separation of the flow logic from the application code seems to be promising, workflow technology has not yet been broadly used in healthcare environments. In this paper we elaborate both the potential and the essential limitations of IT support for healthcare processes. We identify different levels of process support in healthcare, and distinguish between organizational processes and the medical treatment process. To recognize the limitations of IT support we adopt a broad socio-technical perspective based on scientific literature and personal experience. Despite of the limitations we identified, undeniably, IT has a huge potential to improve healthcare quality which has not been explored by current IT solutions. In particular, we indicate how advanced process management technology can improve IT support for healthcare processes.

IT support for healthcare processes - premises, challenges, perspectives

Background
The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering ‘computer reminders’.

Objectives
To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

Search methods
We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

Selection criteria
Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

Data collection and analysis
Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

Main results
Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. 

In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

Authors' conclusions
Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

The effects of on‐screen, point of care computer reminders on processes and outcomes of care

Electronic health record (EHR) implementation is currently underway in Canada, as in many other countries. These ambitious projects involve many stakeholders with unique perceptions of the implementation process. EHR users have an important role to play as they must integrate the EHR system into their work environments and use it in their everyday activities. Users hold valuable, first-hand knowledge of what can limit or contribute to the success of EHR implementation projects. A comprehensive synthesis of EHR users' perceptions is key to successful future implementation. This systematic literature review was aimed to synthesize current knowledge of the barriers and facilitators influencing shared EHR implementation among its various users. Covering a period from 1999 to 2009, a literature search was conducted on nine electronic databases. Studies were included if they reported on users' perceived barriers and facilitators to shared EHR implementation, in healthcare settings comparable to Canada. Studies in all languages with an empirical study design were included. Quality and relevance of the studies were assessed. Four EHR user groups were targeted: physicians, other health care professionals, managers, and patients/public. Content analysis was performed independently by two authors using a validated extraction grid with pre-established categorization of barriers and facilitators for each group of EHR users. Of a total of 5,695 potentially relevant publications identified, 117 full text publications were obtained after screening titles and abstracts. After review of the full articles, 60 publications, corresponding to 52 studies, met the inclusion criteria. The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities. This systematic review presents innovative research on the barriers and facilitators to EHR implementation. While important similarities between user groups are highlighted, differences between them demonstrate that each user group also has a unique perspective of the implementation process that should be taken into account.

/pdf/comparison-of-user-groups-perspectives-of-barriers-and-2zgy6hq1ug.pdf

Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review.

The impact of computerized physician medication order entry in hospitalized patients--a systematic review.

Handover of patient care has been an ongoing problem within the health care sector. The process remains highly variable and there is a threat to patient safety. Despite the general belief that handover transitions in patient care have become routine, not enough attention or research has been directed at improving this period of care. For this reason there is a need to provide an analysis of the communication processes during handover. A study was conducted of the handover process among doctors during shift changes within a hospital setting. The results suggested a need for process change. Results revealed a handover process which was unstructured, informal and error prone, with the majority of doctors noting that there was no standard or formal procedure for handover. The research found that the majority of hospital doctors recognised the potential benefits of formalising and computerising this process.

/pdf/a-description-of-handover-processes-in-an-australian-public-3srb3026t1.pdf

A description of handover processes in an Australian public hospital

Medication errors are common in public hospitals, with the majority at the prescribing stage of the medication pathway. Electronic prescribing decision support (EPDS) is a rules-based computer system that can be used by clinicians to warn against such errors to improve patient safety and support staff workflows. Despite its apparent advantages, this technology has not been widely adopted in Australian public hospitals for inpatient prescribing. A case study using Sauer's (1993) Triangle of Dependencies Model was conducted in 2003 into the feasibility of implementing an EPDS system at an Australian public hospital in New South Wales. It was found not feasible to implement an EPDS at the hospital studied due to the legacy patient administration system, low availability of information technology on the wards, differing stakeholder views, legislation, and the Independent Pricing and Regulatory Tribunal of NSW report recommendations. A statewide standard was preferred, with an agreed specification framework identifying basic core data items and functions that an EPDS must meet which can then be used by area health services to: (i) choose a solution which best meets their contextual needs; and (ii) engage vendors to tender for building an open source (non-proprietary) system based on the specification framework.

/pdf/the-feasibility-of-implementing-an-electronic-prescribing-1duirref9q.pdf

The feasibility of implementing an electronic prescribing decision support system: a case study of an Australian public hospital.

This article is based on a major empirical study of the state of adoption of Computerised Medical Records (CMRs) among General Practitioners (GPs) in Australia and Sweden. Responses were gained from a mail out questionnaire to random samples of GPs in both countries (n = 600/country). This paper will report on the main findings gained emphasising some of the various similarities and differences between the two sample groups. This comparative study adds to the existing body of CMR literature by way of providing a cross cultural perspective on GP adoption states. As a result, some concluding comments are offered for understanding high and low diffusion rates of CMRs among GPs and the implications for health policy and technology adoption strategies.

A comparative study of computerised medical records usage among general practitioners in Australia and Sweden.

Research into patient attitudes towards the use of technology in health care needs to be given much greater attention within health informatics Past research has often focused more on the needs of health care providers rather than the end users This article attempts to redress this knowledge bias by reporting on a case study of the responses gained from patients in a selected Australian medical practice towards the use of computerised medical records and unique identifiers The responses (n=138) were gained from a survey of patients over a 13 day period of practice operation This case study serves as an example of the type of future consumer health informatics research which can be undertaken not just in Australia but also in other countries, both at local regional levels and at a national level

An Australian case study of patient attitudes towards the use of computerised medical records and unique identifiers.

Web-based consumer health information portals are on the increase. With such a large number of health related sites available, design and information quality are key concerns. This article provides an evaluation framework based on the work of Slack (2001) and the HONcode guidelines. Research shows that greater transparency is needed with regard to how rating instruments are constructed and validated. The consumer health portal index developed in this research has been tested for face and content validity through a series of focus groups following Sullivan's 5 step process.

David Bomba

Papers

A description of handover processes in an Australian public hospital

The feasibility of implementing an electronic prescribing decision support system: a case study of an Australian public hospital.

A comparative study of computerised medical records usage among general practitioners in Australia and Sweden.

An Australian case study of patient attitudes towards the use of computerised medical records and unique identifiers.

Constructing and validating a consumer health portal rating index.