Center for Injury Research and Prevention

Hidden Health IT Hazards: A Qualitative Analysis of Clinically Meaningful Documentation Discrepancies at Transfer out of the Pediatric Intensive Care Unit

TitleHidden Health IT Hazards: A Qualitative Analysis of Clinically Meaningful Documentation Discrepancies at Transfer out of the Pediatric Intensive Care Unit
Publication TypeJournal Article
Year of Publication2019
AuthorsOrenstein EW, Ferro DF, Bonafide CP, Landrigan CP, Gillespie S, Muthu N
JournalJAMIA Open
Volume2
Issue3
Pagination392-398
Date Published10/2019
Type of ArticleJournal
ISSN2574-2531
Keywordselectronic health records, hospital communication systems, medical errors, patient handoff
Abstract

Objective: The risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors.

Materials and Methods: Two physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression.

Results: We identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2-90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%-29%).

Conclusion: Clinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.

DOI10.1093/jamiaopen/ooz026
Alternate JournalJAMIA Open
PubMed ID31984372
PubMed Central IDPMC6951953