By Kathleen Stillwell, MPA/HSA, RN, Senior Patient Safety Risk Manager, The Doctors Company

Hospitalists face liability risks based on their diverse roles as an inpatient’s attending physician, covering physician, consultant, supervising physician, and/or co-manager. Two common problems arise: (1) confusion regarding the hospitalist’s responsibilities in the patient care continuum and (2) miscommunication during different phases of inpatient care, especially during handoffs. The following strategies can help hospitalists reduce liability risks.

Clarify Roles and Scope of Care

First, ensure that you, your group, and the hospital all agree on your job description and privileges. This information should be in writing and reviewed during onboarding.

Explain your role as hospitalist to the patient and family. For example, are you covering for the attending physician or serving as the attending physician? Who will coordinate care with specialists? Allow the patient and family time to ask questions.

To avoid confusion among the healthcare team, clarify your role with the other care practitioners regarding the specific components of a patient’s care plan. Participate in team briefs on the patient’s condition, treatment, and team member responsibilities.

Prevent Diagnosis Errors

Implement the following risk mitigation strategies to reduce your risk of diagnostic error: 

• Always consider a differential diagnosis.
• Follow up on laboratory tests and procedure reports.
• Do not delay requesting a consultation.
• Obtain input from other multidisciplinary team members and the patient.
• Document the rationale for your diagnostic decisions. Complete and timely documentation not only enhances patient care, but it also acts as your silent witness in strengthening credibility if you are called upon to defend your care.

Use Standardized Communication Tools and Protocols

Standardized communication tools, methods, forms, templates, checklists, and protocols—such as the SBAR format utilizing Situation, Background, Assessment, and Recommendation—are helpful in managing communication among practitioners. At a minimum, communicate the patient’s diagnosis, current condition, recent changes in condition or treatment, and any anticipated changes. Find out which communication tools or protocols the hospital uses.

Use only approved medical interpreters. Document the name of the interpreter according to facility policy. The patient’s family or guest is not an appropriate interpreter. Use the hospital-approved interpreter services when communicating with a patient who does not speak English.

Checklists can be helpful in obtaining basic yet vital patient information from either the patient or the primary care practitioner. Find out the patient’s code status, current medical status, preferences, medications, testing (completed, pending, and planned), and any new diagnosis so that you have all the information necessary to effectively manage the patient’s care. Use standardized handoff tools to increase patient safety during shift changes, and include an update on changes in the patient’s condition that occurred during your shift. For any complex patients, consider conducting shift change handoffs at the bedside.

Be Aware of Risky Transitions

Transitions in hospital care can occur many times in the course of a patient’s treatment. Good communication among practitioners during patient transitions is essential. Communication breakdowns—compounded by human factors such as fatigue, distractions, and reliance on memory—are common threads noted in malpractice claims.

Hospitalized patients are most vulnerable to communication breakdowns during the following transitions:

• Admission to and discharge from the hospital.
• Transfer between hospital units or to a different department, such as diagnostic testing.
• Transfer to a consultant.
• Handoff to another clinician when a clinician goes off duty or on vacation.

Structure Effective Handoffs

Human errors during care transitions are multiplied when workload, hour restrictions, or other factors increase the number of handoffs. Standardizing the handoff process has been shown to lower rates of near-miss events and adverse outcomes.

Use the following questions to organize handoff communications:

• What information is important to communicate?
• Who needs to know what information?
• When should communication occur?
• How should the information be transmitted?
• Will the person receiving the information have an opportunity to ask questions?
• How can I validate that communication was successful?

These strategies can help decrease human errors during the handoff process:

• Employ technology whenever possible. Effective handoffs are facilitated when the EHR is linked automatically to handoff tools and includes demographic data, problem lists, code status, medications, allergies, consultants, and historical and social information.
• Implement a structured handoff protocol. Communicating required information in a consistent way helps decrease human error.
• Communicate any anticipated patient care problems, including pending laboratory results, procedures, or consultations.
• Conduct face-to-face handoff communications in areas that are free of interruptions, and provide an opportunity to ask questions and clarify care needs.
• Listen actively and take notes. If possible, find a quiet area for the handoff.
• Include multidisciplinary team members, the patient, and family members as needed. Do not rely on the patient or family members to communicate vital information to other practitioners.

Manage Coverage Change

Patients should always know who is taking care of them. During coverage changes, a hospitalized patient may be overwhelmed when a new caregiver comes into the room. Without proper introductions and good handoffs, the patient can easily become confused—which puts you at risk. Follow these strategies for managing coverage changes:

• Introduce yourself by name, and always let your patient know who will be taking over for you. Consider handing the patient your colleague’s business card or using the whiteboard, if available. Provide the patient with the name of and information about the hospitalist who will be available after your shift ends. Explain how to contact the on-duty hospitalist.
• Use a transitions or handoff checklist to ensure that all information is included. This type of tool allows you to rely less on your memory.
• Identify any issues that the patient feels should be communicated to the subsequent treating hospitalist.
• Discuss with the patient and family how pending tests, consults, and the treatment plan will be handled going forward.
• Document a recap of the care provided and outline any follow-up issues.

Standardize Training

These strategies can help you standardize training on how to conduct successful handoffs with other practitioners:

• Engage the hospital staff in the training for handoff communications using a standardized communication tool.
• Identify champions in the handoff process and provide positive reinforcement when handoffs follow established standardized procedures.
• Monitor the success of interventions to improve handoff communications.
• Use lessons learned to facilitate continuous improvement in the handoff process.

Understanding where and how gaps occur in handoff communications is essential to supporting quality and continuity of care. Every practitioner who passes care of the patient to another plays a key role in improving this aspect of patient safety.

For assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.