Quality of the handover of patient care: a comparison of pre-hospital and emergency department notes

Murray, Stephen L., Crouch, Robert and Ainsworth-Smith, Mark (2012) Quality of the handover of patient care: a comparison of pre-hospital and emergency department notes. International Emergency Nursing, 20 (1), 24-27. (doi:10.1016/j.ienj.2010.09.004). (PMID:22243714)

Abstract

Aim
The aim of this audit was to evaluate the accuracy of patient information transfer from pre-hospital reports to Emergency Department (ED) documentation.

Methods
The records of 100 patients seen in the ED resuscitation room of a UK hospital were compared using a pro-forma designed by the research team. Sections of the ambulance service patient report form and the ED documentation were compared for differences. The history of the event leading to the 999 call, the patient’s previous medical history, prescribed medications, allergies and any treatment carried out by the ambulance crew were analysed.

Results
Of the 100 records, 26 had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer. These fell into various categories including the previous medical history of the patient, the timings of the event bringing them to hospital, frequency of the event occurring, allergies and medications.

Conclusion
This audit quantifies the number of patient encounters where written information changes or is lost when care is passed from pre-hospital to hospital staff in the resuscitation room. We have not investigated other parts of the ED or the verbal transfer of information. Further work investigating the causes of these changes in information, any impact on patient care and whether this occurs in other parts of an ED is suggested.

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