Residents' Self-Perceived Errors in Transitions of Care in the Emergency Department

BACKGROUND: The Accreditation Council for Graduate Medical Education requirements for systems-based practice state residents are expected to participate in identifying system errors and implementing potential systems solutions. The objective of this study was to determine the numbers of perceived errors occurring from patient pass offs between resident physicians in our emergency department.

METHODS: Using a prospective observational study, we queried emergency medicine residents about perceived errors in the transition of care using trained research assistants and a standardized protocol. Transition of care was defined as the transfer of responsibility to evaluate and treat and disposition of a patient in the emergency department from 1 resident physician to a second oncoming emergency department resident physician. Mean resident-perceived errors per shift and per patient transfer of care were calculated. Additionally, the mean number of perceived errors impacting patients was calculated.

RESULTS: Emergency medicine residents on 107 shifts reported receiving 713 patients in pass off with a mean of 7 patients per physician per shift, with 40% of patients passed off needing some intervention (mean of 2.8 patients per provider per shift). Nineteen of the 107 shifts (17.8%) during which a resident took patients from a prior provider had a perceived error in at least 1 patient signed off. Of the 713 patients transitioned, the receiving physician perceived an error related to the transition of care for 23. Two of the 23 errors were determined by reviewing emergency medicine attendings to not be errors, and for 9 the receiving physician perceived an impact on the patient. All were delays in care or disposition.

CONCLUSION: Our data suggest emergency medicine residents were able to perceive errors related to transitions of care, describe the types of pass-off errors, and, to a lesser degree, describe the impact these errors have on patients.