Bhabra Gevdeep, Mackeith Samuel, Monteiro Pedro, Pothier David D
Department of Otolaryngology, St Michael's Hospital, Southwell Street, Bristol, UK.
Ann R Coll Surg Engl. 2007 Apr;89(3):298-300. doi: 10.1308/003588407X168352.
With the increase in shift pattern work for junior doctors in the NHS, accurate handover of patient clinical information is of great importance. There is no published method that forms the gold standard of handover and there are large variations in practice. This study aims to compare the reliability of three different handover methods.
We observed the handover of 12 simulated patients over five consecutive handover cycles between SHOs on a one-to-one basis. Three handover styles were used and a numerical scoring system assessed clinical information lost per handover cycle.
After five handover cycles, only 2.5% of patient information was retained using the verbal-only handover method, 85.5% was retained when using the using the verbal with note taking method and 99% was retained when a printed handout containing all patient information was used.
When patient information is handed over by the verbal only method, very few facts are retained; therefore, this method should be avoided whenever possible. Verbal handover with note taking is shown to be an effective method of handover in our study, although we accept that this is an artificial scenario and may not reflect the reality of a busy hospital. Nearly all information is retained by the printed handout method but this relies on the handout being regularly updated.
随着英国国家医疗服务体系(NHS)初级医生轮班工作模式的增加,准确交接患者临床信息至关重要。目前尚无已发表的方法可作为交接的金标准,且实际操作存在很大差异。本研究旨在比较三种不同交接方法的可靠性。
我们一对一地观察了住院医师连续五个交接周期内对12名模拟患者的交接情况。使用了三种交接方式,并采用数字评分系统评估每个交接周期丢失的临床信息。
经过五个交接周期后,仅使用口头交接方法时,仅保留了2.5%的患者信息;使用口头交接并做记录的方法时,保留了85.5%的信息;而使用包含所有患者信息的打印资料时,保留了99%的信息。
仅通过口头方式交接患者信息时,保留的信息极少;因此,应尽可能避免使用这种方法。在我们的研究中,口头交接并做记录被证明是一种有效的交接方法,尽管我们承认这是一个人为设定的场景,可能无法反映繁忙医院的实际情况。通过打印资料交接几乎能保留所有信息,但这依赖于资料的定期更新。