Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.
OBJECTIVE
We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers.


METHODS
We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques.


RESULTS
Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; "boarding" in the ED; and ambiguous responsibility for sign-out or follow-up.


CONCLUSIONS
The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT 06510, USA. leora.horwitz@yale.edu
Leora I
LI
Horwitz
Thom
T
Meredith
Jeremiah D
JD
Schuur
Nidhi R
NR
Shah
Raghavendra G
RG
Kulkarni
Grace Y
GY
Jenq
D000046:Academic Medical Centers; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D003625:Data Collection; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D033183:Interdisciplinary Communication; D019300:Medical Errors; D010343:Patient Admission; D010360:Patient Transfer; D010820:Physicians; D014481:United States; D016526:Workload