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"Lost in public discussions is the link between these multiple hand offs and the possiblity of errors. This discontinuity is a real problem. One the few studies that addresses this key issue is by L.A. Petersen and others; its results are reported in 'Does housetaff discontinuity of care increase the risk for preventable adverse events?' (9) This case-controlled study of more than 3,000 patients in an urban teaching hospital showed that yes, increasing hand offs increase errors. Researchers concluded that 'patients who had potentially preventable adverse events were more than twice as likely to be covered by an intern from another team or the night float resident...as were matched control patients in adjacent beds (26% compared to 12% p<0.05).' The problem of errors and cross covering has received very little attention from our own profession, and systems need to be developed to deal with this." Michael J. Zinner in Bulletin of the American College of surgeons, Volume 87, Number 3, March, 2002.
(9) Peterson LA, Brennan TA, O'Neil AC, et al: Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Int Med, 121:866-872, 1994.
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