Frequency of safety net errors in the emergency department: Effect of patient handoffs

Abstract

Objectives: The objective of this study was to determine physician awareness of abnormal vital signs and key clinical interventions (oxygen provision, intravenous access) in the emergency department, and to measure the effect of patient handoffs on this awareness.

Methods: This was a prospective observational study at two large, urban, academic emergency departments. Emergency department physicians were asked the following about each of the physician's patients: 1) the number of IV lines, 2) whether the patient was on supplemental oxygen, and 3) whether the patient had any abnormal vital signs. Physicians were blind to the nature of the study prior to enrollment. Error rates between physician responses and actual patient status were calculated, and logistic regression, adjusted for physician clustering, was used to calculate association of errors with multiple situational factors, including handoff status.

Results: We analyzed 463 patient encounters from 74 physicians. Physicians missed abnormal vital signs in 19.4% of encounters. They made errors in oxygen status and number of IV lines in 16.6% and 35.8% of encounters, respectively. Physicians were significantly more likely to make all types of errors on patients who had undergone handoff as opposed to their primary patients.

Conclusion: Emergency physicians make frequent errors regarding awareness of their patients' vital signs, oxygen and vascular status and patient handoffs are associated with an increased frequency of such errors.

Keywords: Handoffs; Patient safety; Safety net.