Handoff notes are increasingly integrated within electronic health record (EHR) systems and often contain data automatically generated from the EHR and free-text narratives. We examined the quality of data entered by providers in the free-text portion of our institutional EHR handoff tool. Overall, 65% of handoff notes contained at least one error (average 1.7 errors per note). Most errors were omissions in information around patient plan/management or assessment/diagnosis rather than entry of false data. Factors associated with increased error rate were increasing hospital day number; weekend note; medical (vs. surgical) service team; and authorship by a medical student, first or fourth year resident physician, or attending physician. Our findings suggest that errors are common in handoff notes, and while these errors are not completely false data, they may provide individuals caring for patients an inaccurate understanding of patient status.
Download full-text PDF |
Source |
|---|
Publication Analysis
Top Keywords
Similar Publications
Improving Patient Handoffs and Transitions in Care Among Residents: A Chief Resident-Led Initiative.
Cureus
November 2024
Pediatrics, Valley Children's Healthcare, Madera, USA.
Introduction: Effective handoff between pediatric residents is crucial to ensure continuity of care and patient safety. Omissions in information and communication breakdowns can be associated with uncertainty in clinical decision-making and adverse patient events. In our role as chief residents, we were notified of an increase in patient safety alerts due to communication failures and gaps during handoff.
View Article and Find Full Text PDFDeveloping and Evaluating Large Language Model-Generated Emergency Medicine Handoff Notes.
JAMA Netw Open
December 2024
Department of Emergency Medicine, NewYork-Presbyterian/Weill Cornell Medicine, New York.
Importance: An emergency medicine (EM) handoff note generated by a large language model (LLM) has the potential to reduce physician documentation burden without compromising the safety of EM-to-inpatient (IP) handoffs.
Objective: To develop LLM-generated EM-to-IP handoff notes and evaluate their accuracy and safety compared with physician-written notes.
Design, Setting, And Participants: This cohort study used EM patient medical records with acute hospital admissions that occurred in 2023 at NewYork-Presbyterian/Weill Cornell Medical Center.
Diagnostic Uncertainty Among Critically Ill Children Admitted to the PICU: A Multicenter Study.
Crit Care Med
November 2024
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
Article Synopsis
- This study focused on understanding how common diagnostic uncertainty is when critically ill children are admitted to Pediatric Intensive Care Units (PICUs) and what factors contribute to it.
- Researchers reviewed medical records from 882 pediatric patients across four hospitals to assess the presence of diagnostic uncertainty at admission and how it changed by the time of discharge.
- Key findings indicated that 25.9% of patients showed diagnostic uncertainty upon PICU admission, with significant factors being the time of admission, illness severity, atypical symptoms, and discrepancies in diagnoses between different healthcare providers.
Understanding the Relationship Between Critical Care Nurses' Perception of Patient Safety Culture and Adverse Events.
SAGE Open Nurs
November 2024
Critical Care and Emergency Nursing Department, Faculty of Nursing, Damanhour University, Damanhour, Egypt.
Article Synopsis
- This study explored how critical care nurses in Egypt perceive patient safety culture and its link to adverse events affecting patient care.
- Findings showed low positive responses in critical areas like staffing and teamwork, with many nurses having a moderate to high perception of overall patient safety.
- A significant relationship was found between poor safety culture perceptions and higher incidences of adverse events, such as patient falls and drug-related issues, particularly among nurses with certain demographics and experience levels.
The Communication Conundrum: A Pilot Cross-Sectional Descriptive Examination of Family Nurse Perspectives Surrounding Patient Information Exchange During Interfacility Patient Transfers in Montana.
Res Theory Nurs Pract
August 2024
School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA.
Interfacility patient transfers are fraught with issues such as missed or ineffective communication in Montana given wide geographic distance between facilities and variance in resources. Inaccurate, absent, or delayed patient details may negatively affect patient outcomes and further result in duplicative testing and medication errors. The objective of this study was to describe the process of patient information communication during interfacility transfers as perceived by nurses practicing in Montana.
View Article and Find Full Text PDFWant AI Summaries of new PubMed Abstracts delivered to your In-box?
Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!