- Provide an overview of transitions in
continuously operating industries
- Review cognitive error
- Describe the complex dynamics of
transitions in emergency care
- Provide suggestions to decrease risk at
A 41-year-old woman came to the emergency
department (ED) with mental status changes. She had been diagnosed
with a urinary tract infection and started on oral ciprofloxacin 4
days earlier. She had fever, nausea, and vomiting in the days
preceding presentation. She did not have headache, focal weakness,
or numbness. Past medical history was otherwise
On physical examination, the patient was
afebrile, with sinus tachycardia (heart rate 123 beats per minute)
and otherwise normal vital signs. Able to follow most commands, she
was alert but oriented to person and place only. Neurologic
examination was otherwise non-focal. There were no signs of
Approximately 40 minutes after the patient
arrived, initial laboratory results returned and included white
blood cell count 12.7 K/µL with 89% granulocytes, hematocrit
20.2%, glucose 204 mg/dL, blood urea nitrogen 36 mg/dL, serum
creatinine 1.4 mg/dL. Urinalysis showed moderate blood. Platelet
count was pending at that time.
Sixty minutes after arrival, the patient was
admitted to the internal medicine service with a diagnosis of
anemia and hematuria in the setting of a urinary infection. The
medicine team completed the admission paperwork, with plans to
administer empiric broad-spectrum antimicrobial agents and packed
red blood cells for the severe anemia. The outgoing ED physician
had just completed the shift and signed the patient out to the
oncoming colleague as “admitted,” with care already
transferred to the internal medicine service.
Transitions are necessary in any industry with
continuous operations, and health care is no exception. Shift
changeover occurs when two or more workers exchange
mission-specific information, responsibility, and authority for an
This moment of care has been characterized as both an opportunity
for rescue and a threat to safety.(2,3)
Most health care teams now consist of far more than one nurse and
one physician—with each additional worker responsible for
care, the potential for error or rescue increases. The ability to
effectively conclude one level of care and transfer to the next is
critical to quality and safety in the ED.
Any discussion of shift changeover involves the
complex interplay of two or more individuals working in a broader
system. Certain features are common to most ED handoffs. Geography
often dictates a starting and ending point (ie, bed 1-10).
Interruptions occur frequently. Physicians often perform sign-over
separately from nurses and other specialists. The chart or other
formal written documentation is rarely used for transitions.
On the other hand, many of the aspects of ED
transitions are highly variable.(4)
Transition can occur in front of the patient, at a remote setting,
or anywhere in between. The hand-off can be predominantly
interactional or transactional. That is, the transition may be a
two-way dialogue that leads to “shared sense-making,”
or it can be a one-way purge of information. In all cases, the
ongoing demands of the ED necessitate that handoffs be
characterized by both brevity and completeness.
Although few EDs have formal systems for
transition, one can identify four phases in most ED
These phases include (i) pre-turnover, (ii) arrival, (iii) meeting
period, and (iv) post-turnover. These phases tend to be common in
all health care settings with high consequences for failure, like
Examples of effective transition can be found in
reliable organizations such as nuclear powered submarines,
trauma centers, and NASA. Los Angeles–class nuclear
submarines use “precise, unambiguous, impersonal, and
efficient” language between the officer on duty and the sonar
technician to navigate safely. Commands, readbacks, and monitoring
help bridge authority
gradients and ensure the crisis-resistant performance vital to
Dedicated local and regional trauma centers also depend on
operational and clinical excellence to achieve
“failure-resistant performance.” For example, a trauma
nurse asks if anyone has informed the operating room (OR) of a
patient’s pending transfer to the OR. Acknowledgment and
action from the team leader follow this inquiry, ensuring that all
the providers have situational
awareness and that there is timely transit to the OR.(9)
These are only a few of the useful strategies. In fact, in an
article on handoff strategies, Patterson describes 21 techniques
used by NASA, nuclear power plants, railroad dispatch centers, and
ambulance dispatch centers.(10)
The techniques include verbal, face-to-face, and interactive
questioning that is coordinated with written summaries prior to
shift change. Additionally, readback, limits on interruptions,
unambiguous transfer of responsibility, and pre-turnover data scans
are all used to ensure joint sense-making at the completion of
Four hours after arrival, the laboratory
called the ED to report a critical lab result, a platelet count of
4,000/mm3 (normal range 150,000-400,000). The critical
result was received by the ED unit secretary. It is unclear who
this information was passed on to, but neither the ED attending nor
the internal medicine service was made aware of this lab
Sixteen hours after the patient presented to
the ED, the internist noted the abnormal finding when checking the
morning lab data. She made a tentative diagnosis of thrombotic
thrombocytopenic purpura (TTP). The patient required transfer to
the ICU because of progressive deterioration in mental status and
was eventually intubated. Hematology consultation was obtained to
initiate emergent plasma exchange for treatment of TTP.
The evaluation of mental status change demands
the best of the entire health care team. Work-up and decision
making vary from patient to patient and fit poorly into clinical
care algorithms. Care must be customized. Arriving at the correct
diagnosis often involves multiple practitioners; lengthy, detailed,
and occasionally invasive work-up; and explicit attention to
detail. TTP is a rare (15 patients per million per year) clinical
syndrome characterized by low platelets, anemia, fever, mental
status change, and acute renal failure. Accurate evaluation,
diagnosis, and treatment of TTP are barometers of both the
competency of individual providers and their teams, as well as the
quality and safety of the system. Transitions in care magnify
weaknesses present in individuals, teams, or the broader
Communication and Cognition:
Evaluating System and Human Actions
Given the rarity of TTP and the often ambiguous
and non-specific clinical presentation (eg, fever, anemia),
cognitive errors are common and often lead to delays in diagnosis.
The disease is fatal in up to 90% of cases without effective
treatment, but prompt treatment with plasma exchange can be
In this case, two major mishaps resulted in late administration of
plasma exchange, the communication of serious lab abnormalities,
and the recognition of the clinical entity, TTP.
Communication and the System: Failure
to Identify Serious Laboratory Abnormality
A combined human and system error resulted in
delay in acknowledgment of low platelets. At sign-out, the
“platelet count was pending.” Two human-transition
issues arise. First, most clinicians recognize that a delay in
reporting a test often means the result is abnormal (the extra time
reflects the lab’s protocol to perform further authentication
prior to reporting the test result to the caregivers). Thus,
knowing that all other CBC results were obtained should raise the
suspicion that the unreported platelet count was abnormal. Making
this assumption, the outgoing team must make it explicitly clear
this test result should be evaluated prior to disposition or
further management. Additionally, the outgoing team must ensure
that the incoming team has clearly understood this request and the
reason for it. The most notable system error is that there simply
was no consistent process established to deliver the information to
the care team.
A variety of methods are used in the ED and
across health care to communicate important information such as
critical test results. Direct, face-to-face communication is
frequently the most desirable and effective way of assuring
flawless transfer of information. However, indirect methods such as
text-paging, email alerts, indirect communication (via overhead
calls or two-way messaging), color-specific paper charting, or
written documents are also used to deliver ancillary test results.
Whatever method is chosen (direct communication is the best), it
also needs to be coupled with a shared interpretation of what
constitutes critical results. Such interpretations cannot be made
in a vacuum but require an appreciation of each patient’s
unique characteristics. For example, a hematocrit of 24% in a
patient with coronary disease and no history of anemia constitutes
a medical emergency, while the same hematocrit in a young patient
with chronic renal insufficiency would barely elicit a yawn.
Cognition and the Human: Failure to
Reach the Correct Diagnosis
In this case, errors occurred at several of the
transitional phases: pre-turnover, meeting, and post-turnover. In
the pre-transition phase, the ED doctors were content with the
diagnosis of urinary infection as the cause for altered mental
status and demonstrated anchoring bias as
contradicting evidence was set aside. During the transition itself,
it was unclear who was responsible for follow-up and interpretation
of these results—a systems problem. Finally, after the
turnover, the clinicians became subject to a framing effect, as all
the findings were considered in light of the diagnosis of
“urinary tract infection and anemia,” rather than
reconsidering the new information as it came in.(13) In this way, the case illustrated Canadian ED
physician and safety expert Pat Croskerry’s observation,
“When the diagnosis is made, the thinking
Despite these interventions, the
patient’s status continued to deteriorate. The patient died
the following day, within 48 hours of presentation to the
TTP requires timely treatment in order to reduce
mortality. It shares this time dependency with many other ED
diagnoses and situations, many of which have been converted into
quality metrics (eg, 10 minutes to EKG for patients with chest
pain, or 240 minutes to antibiotics for patients with pneumonia).
These time-dependent outcomes invariably rely on many individual
processes and interactions; the transition phase is just one of
these. As Richard Cook notes, “Catastrophe requires multiple
failures—a single point failure is not
Communication failures fall into three
First, system failures occur when communication channels are
used infrequently, are non-functional, or are non-existent. Second,
message failure occurs when there is poor or non-existent
transfer of information. Third, reception failure occurs
with misinterpretation or late arrival of proper information. In
one recent study, a written (computerized) sign-out sheet for
surgical residents augmented verbal sign-out and was widely
was able to centralize and organize information and daily work.
Another recent analysis describes “collaborative
cross-checking” as a way to improve resilience of the health
care transition.(17) In
one illustrative case, a nurse overheard a confusing order at
sign-over and questioned the order with the physician. The order
was re-evaluated, which prevented a potential catastrophe. That
case illustrates that proximity may well be serendipity, and that
cross-checking can serve as a valuable rescue mechanism.
In industries with continuous operations such as
health care, it is vital that we look for tools to improve
resilience at shift transitions. The unique need for customization,
the requirement to manage surges in volume, the varied professional
expertise, and the tight coupling of different processes to each
other make this a challenge. Take-home points for potential
- Reduce transitions when they are not
- Assure clear delineation of authority
and responsibility at times of transition. (“Dr. Smith,
please check the platelet count; it is currently
- When possible, use discrete end-points,
simply communicated. (“If the platelet count returns below
30,000, call hematology.”)
- Describe symptoms and ancillary studies
to support interpretations, particularly when the work-up is
continuing. Use diagnoses only when they are clearly supported.
(“This patient has recently been treated for UTI and presents
with mental status change, hematuria, and anemia,” instead of
“This patient has UTI and anemia.”)
- Encourage and accept cross-collaborative
feedback and questioning.
- Transition—like all high-stakes
technical procedures—should be observed and taught to
students before they become transition leaders.
- Limit interruptions. If interruptions
are necessary, delay transfer of responsibility.
- Use written and verbal tools to augment
Assistant Professor of Emergency Medicine
Northwestern University, The Feinberg School of Medicine
Faculty Disclosure: Dr. Beach has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.
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