# Presentation: 007657

## Spotlight Case November 2008

**Dangerous Shift**

## Source and Credits

- This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available
- Commentary by: **Emily S. Patterson, PhD**Institute for Ergonomics, Ohio State University
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Niraj Sehgal, MD, MPH
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- Review the evidence base on erroneous actions related to shift changes
- Understand the limits of standardizing handoffs in preventing errors at shift change
- Explain basic assumptions about human expertise and error
- Learn three heuristics for effective coordination: Reduce, Reveal, Focus

## Case: Dangerous Shift

*	**A 3-month-old infant was admitted with a respiratory syncytial virus (RSV) infection to a pediatric medical unit. Although she was initially stable (without oxygen requirements), her breathing soon became labored, with an increased respiratory rate and subcostal retractions. Providers determined that she would benefit from a higher level of care and initiated the transfer process. This transfer happened to coincide with a *_*shift change*_* for both the nursing staff and the physicians involved.*

## Case: Dangerous Shift (2)

*	**The off-going nurse assumed the transfer would take place immediately and signed out her patients to the next nurse before the patient was physically moved. The outgoing physician sent a text page to his incoming colleague with similar sign-out. Approximately 45 minutes later, the unit clerk called the infant’s bedside nurse to report that the infant’s parents believed their child was in significant distress. The nurse was surprised the patient had not yet been transferred and, after an initial evaluation, immediately called the rapid response team.** *

## Case: Dangerous Shift (3)

*	**The evening physician was also contacted, and was equally surprised by the series of events. She had been told that the patient was being transferred “non-emergently” to a unit for closer observation. The patient was transferred to the intensive care unit, where she made a full recovery, after a prolonged hospitalization.*

## Shift Changes

- A point of vulnerability in complex systems with high consequences for failure
- Impact of erroneous actions from shift changes attributed to:
- Inaccurate medication prescriptions
- Inaccurate patient evaluations
- Longer length of stays
- Increased use of laboratory tests

*See Notes for references.*

## Standardizing Shift Change Communication

- Specific communication tools can increase the information conveyed about every patient
- They can also promote anticipatory thinking for providers in delivering safe care
- A tool adopted by many institutions to foster structured communication is SBAR, which has four components:
_**S**_ituation
_**B**_ackground
_**A**_ssessment
_**R**_ecommendation

*See Notes for references.*

## Narrative vs. SBAR Update

_**Narrative Update**_
*	**Patient X in Room Y is a 3-month-old with RSV who was initially stable but recently has been having respiratory issues that are getting worse so you need to transfer her to the ICU as soon as possible.*

## Narrative vs. SBAR Update

_**SBAR Update**_
*	**For patient X in Room Y, the patient’s code status is <code status>. The main problem with the patient is respiratory issues. I have assessed the patient personally, and vital signs are BP <data>, pulse <data>, respiration <data>, and temperature <data>. I am concerned about the respiration because it is <data>. The patient's mental status is <data>. The skin is warm and dry. The patient has been on <data> oxygen for <data> minutes. The oximeter is reading <data>. The oximeter does not detect a good pulse and is giving erratic readings. This is what I think the problem is: respiratory distress. The patient seems to be unstable and may get worse, we need to do something. I request that you transfer the patient to critical care.*

## Moving Beyond Standardization

- Structured communication tools don’t resolve the complex nature of health care situations, particularly the trade-offs involved in decision-making (e.g., transfer patient now versus incur more shift changes & sign-outs)
- Assumptions & Lessons from cognitive engineering literature provide guidance (examples on the following slides)

*See Notes for references.*

## Assumptions & Lessons(from Cognitive Engineering)

- _A:_ Human behavior in professional settings is locally rational
- _L:_ Increasing individual motivation and heightening attention (try harder; be more careful) are unlikely to improve performance
- _A:_ All decisions require making trade-offs on competing goals
- _L:_ Sacrifices to safety goals to meet economic and production goals are common occurrences not usually scrutinized when outcome is positive
- A: Imposing a simple standard on a complex process does not result in simplicity
- L: Policies will need to be tailored to particular settings, include contingency plans, and allow for flexibility to deviate in exceptional circumstances

## Assumptions & Lessons (2)(from Cognitive Engineering)

- _A:_ People adapt procedures over time in response to feedback
- _L:_ Policies heavily slanted toward safety goals will likely change over time in response to feedback to respond to acute production and quality of work-life pressures
- _A:_ Communication is not a macrocognitive function, but rather a means to achieve multiple functions in necessarily distributed work
- _L:_ “Failure to communicate” is not a useful diagnostic concept for system improvement

## Assumptions & Lessons (3)(from Cognitive Engineering)

- _A:_ Narratives (“stories”) are primary vehicle for compactly constructing meaning in a shared conversation, rather than a one-way transfer of independent data elements via a noisy communication channel
- _L:_ Handoff procedures that emphasize comprehensive verbal communication of low-level data (e.g., vital signs) in a structured format can make it difficult to quickly understand the “gist” of a patient’s status and plans

## Designing Policies for Shift Changes

*Use an approach that reduces complexity wherever possible to minimize the potential for erroneous actions*
*Use an approach that also increases the ability to detect and recover from such actions*
*Three Heuristics for designing effective policies:*
- Reduce complexity
- Reveal by rendering work observable
- Focus attention

## Heuristic 1: Reduce Complexity

- Evaluate strategies to reduce the need for transfers
- Eliminate redundant documentation
- Eliminate (or streamline) data entry for use at a later time by distant parties (billing/legal/QI)
- “Chunk” together related information that can be tailored to a particular perspective

## Heuristic 2: Rendering Work Observable 

- Develop an “at a glance” visual display of the current status of a work process (e.g., PACU dashboard)
- Dashboards can share a similar structure even if applied in different clinical settings

## Heuristic 3: Focus Attention

- Stratify time and attentional resources during shift change update based on patient instability and level of uncertainty around a diagnosis and treatment plan
- (“Save the sick, do the others quick” strategy)
- Highlight the need to expedite tasks
- Automatically compile data into printed paperwork that can be highlighted, annotated, and discussed verbally during shift updates

## Final Thoughts on the Case...

- Outlined heuristics may not address each and every issue, including ones from this case
- Be cautious with an “ensure that this never happens again” approach following a undesired outcome, as it may serve as a barrier to making health care safer
- Rather than making changes on a single case, explore applying desired trade-off weightings across a range of routine and exceptional cases because a goal of zero adverse outcomes is likely not realistic

**Notes:**
32-35,37

## Take-Home Points

- The evidence base for interventions to improve shift changes is weak
- Alternatives to standardization of handoff updates should be pursued
- Coordination heuristics may provide productive directions to explore