Handoffs and Medication Errors: A Community Hospital Case Study

Abstract

In hospitals, a handoff occurs when responsibility for care of a patient is transferred to another caregiver, along with information about the patient's condition, treatment plans, and orders. Prior studies report that flawed handoffs contribute to adverse events, but few studies have closely analyzed this from an information processing perspective. We report on a case study of medication administration processes and related information quality issues associated with handoffs in one hospital. Applying an interdisciplinary lens (informed by prior work on health care quality, process management, and accounting information systems) this case study reveals evidence that handoffs both contribute to process and data flaws and can help reveal and correct prior errors. Our findings highlight the importance of designing clinical systems and processes that systematically prevent threats to the validity, accuracy, completeness, and timeliness of clinical data and that use handoffs to detect and correct these four types of errors.