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Seven Things To Know When You Receive A Notice Of Investigation From The Department Of Health

Preventing Malpractice


by Michael L. Smith, JD, RRT

When health care providers drop the ball during a patient hand-off, essential care can fall through the cracks resulting in injury to the patient, sentinel events, missed or delayed treatment, and a medical malpractice claim.

A hand-off is the transfer of responsibility for a patient during any transition in the care of the patient. Hand-off communication is the exchange of information between the health care provider relinquishing responsibility for the patient and the health care provider who is assuming responsibility for the patient. A hand-off happens with every change in responsibility for a patient – from coverage for lunch breaks to transfers to different facilities.

The Joint Commission’s Center for Transforming Healthcare estimates that miscommunication during the hand-off is a factor in 80 percent of sentinel events. A sentinel event is any unanticipated event resulting in death or serious physical or psychological injury to a patient in a health care setting that is not related to the natural course of the patient’s illness. Hand-off miscommunication also can cause delayed treatment, the provision of the wrong treatment, and the patient remaining in the hospital longer than necessary. The hand-off communication problem is so severe that the Joint Commission intends to add resources on hand-off procedures to its Targeted Solutions Tool later this year.

What can respiratory therapists do to improve their hand-offs in order to avoid sentinel events and potential malpractice claims? Many hospitals have implemented standardized policies and procedures on how RTs and other health care providers should communicate their hand-offs. Absent a specific policy, RTs need to communicate appropriate information during the hand-off based upon the patient’s condition and the type of hand-off involved. Generally, appropriate information should include the following:

  • the patient’s name
  • the name of the patient’s physician
  • the patient’s diagnosis or immediate medical problem
  • any recent procedures
  • any recent changes in the patient’s condition
  • the time when any additional procedures or treatments are due
  • any unique information relevant to the patient’s care.

The hand-off communication should give the receiving RT the information necessary for the receiving RT to provide the patient’s immediate care without undue delays and definitely without any care falling through the cracks.

Whenever possible, RTs should be providing the hand-off communication verbally. This allows the receiving RT to ask questions and to clarify any discrepancies. However, in some circumstances RTs may be required to provide hand-off information in writing. Any written hand-off communication should still include all the necessary information for the receiving RT to handle the patient’s immediate needs.

RTs should limit their hand-off communication to only the essential information. Most RTs probably know at least one RT who consistently provides too much extraneous information during hand-off communication. Too much information during a hand-off can obscure the important information necessary for the patient’s continued care.

The RT handing-off the patient should document that the hand-off communication was delivered and the name of the receiving RT. Documentation of hand-off communication is especially important when transferring patients to other facilities. Unfortunately, transfers between facilities pose a greater risk of delayed or missed care and a greater risk of medical malpractice claims. Your hand-off communication cannot guarantee that the receiving facility will not have a misstep, but documentation of your hand-off communication may show your facility did not contribute to the problem.

Michael L. Smith, JD, RRT is board certified in health law by The Florida Bar and practices at The Health Law Firm in Altamonte Springs, Florida. This article is for general information only and is not a substitute for formal legal advice.

This article was originally published in Advance for Respiratory Care and Sleep Medici