Transitions in patient care do not occur without negative consequences. We have known for more than 20 years that a cross-covering physician dramatically increases the risk of preventable adverse events.1 The 2003 implementation of duty hour restrictions increased the number of handoffs required for care of inpatients; these changes also led many to question whether duty hour restrictions were a benefit or detriment to patient safety, with both medicine and surgery residents indicating that patient harm commonly resulted from handoffs.2 No place is there more potential for patient harm resulting from handoffs than the intensive care unit (ICU), owing to patients’ severity of illness and the resulting complexity of this patient population.
Cochran A. Standardized Handoffs in the Intensive Care Unit: Hope or Hype for Improving Critical Care? JAMA Surg. 2018;153(5):470. doi:10.1001/jamasurg.2017.5468
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