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The lead article in a special supplement on clinical handover in the Medical
Journal of Australia relates a tragic case in which an elderly man died for
want of effective handover.
The ageing Indigenous man was evacuated to Katherine Hospital with pneumonia.
The first failure in handover came when he travelled alone despite a previous
recommendation from a doctor that he be accompanied by a family member because
of his poor English and frail condition.
After nine days’ treatment he was flown back to the airstrip some distance
from the town. A fax on his discharge was sent to the local community health
facility, but it was not acted upon and there was no check in place with the
travel service.
The pilot left the patient at the airstrip, assuming someone was going to pick
him up.
Three days later the police were informed that he was missing. His body was
subsequently found – he had died alone, dehydrated and suffering from
pneumonia.
This distressing event was related by Dr Christine Jorm and colleagues, of
the Australian Commission on Safety and Quality in Health Care, to illustrate
the human consequences of poor communication on handover.
“Since this tragic incident, the Northern Territory Government
has taken steps to standardise and improve handover processes but health professionals
need to acknowledge that handover is always… integral to the delivery
of safe patient care,” Dr Jorm said.
Problems that can arise from poor communication at handover include incorrect
medication, delays or failures in treatment, duplication of diagnostic testing
and preventable readmissions.
These failings waste time, strain health care resources and cause harm to patients.
The poor outcomes that arise from poor handover, and the scarcity of evidence,
have motivated the Australian Commission on Safety and Quality in Health Care
to develop evidence-based solutions for improving handover.
Dr Jorm introduces a number of themes on the issue of handover that are explored
in the MJA supplement, including the importance of clinical involvement in the
quality improvement process and the need for “flexible standardisation”.
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Ltd.. Material in this news item was released by the Australian based source
listed below on 31 May 2009
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