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Difficulty: MediumTransitions of Care and Handoff Protocols

A 58-year-old man is hospitalized for an acute pulmonary embolism and is started on a therapeutic heparin infusion. His past medical history is significant for severe, recurrent peptic ulcer disease. At 6:00 PM, the primary daytime physician transitions care to the night-shift cross-cover physician. The verbal and written sign-out provided is: "58-year-old man with a pulmonary embolism on a heparin drip. Stable for the floor. Follow up on the evening partial thromboplastin time (PTT); target is 60 to 80 seconds. Call if there are any issues."

At 9:00 PM, the patient complains of a severe tension-type headache. The cross-cover physician, who is managing multiple urgent issues on the ward, quickly reviews the sign-out note and prescribes intravenous ketorolac for pain relief. Two hours later, the patient develops massive hematemesis and hemorrhagic shock.

Which of the following components of a structured handoff protocol (e.g., I-PASS) was most critically deficient in the daytime physician's sign-out, directly contributing to this adverse event?

  1. Patient summary detailing active comorbidities and baseline risk factorsAnswer
  2. B
    Contingency planning providing explicit 'if-then' directives for anticipated changes
  3. C
    Synthesis by the receiver utilizing teach-back to confirm understanding
  4. D
    Illness severity assessment to determine appropriate patient disposition
  5. E
    Action list delineating pending tasks and absolute pharmacologic contraindications

Answer

The most critically deficient component was the patient summary detailing active comorbidities and baseline risk factors.
The correct answer correctly identifies that the patient summary was the critical deficiency. In standardized handoff frameworks like I-PASS, the 'Patient Summary' is designed to convey the hospital course, active issues, and critical baseline comorbidities. The daytime physician failed to include the patient's history of severe peptic ulcer disease. When the patient developed an unanticipated issue (headache), the cross-cover physician, relying on this incomplete summary, prescribed ketorolac. The combination of an NSAID, therapeutic heparin, and underlying peptic ulcer disease led to life-threatening hemorrhage. A complete patient summary would have prevented this error.

Step-by-Step Solution

1
Analyze the adverse event to determine the root cause.
The patient developed a massive gastrointestinal hemorrhage because the cross-cover physician prescribed ketorolac (an NSAID) to a patient on a heparin infusion who had a history of peptic ulcer disease.
Identifying the mechanism of injury isolates the exact failure point in the clinical workflow.
2
Evaluate the provided sign-out communication against standard handoff frameworks.
The sign-out included an illness severity assessment ('Stable for the floor'), an action list ('Follow up on evening PTT'), and a weak contingency plan ('Call if any issues'). It completely omitted the patient's critical past medical history of severe peptic ulcer disease.
Comparing the actual handoff to a gold standard (like I-PASS) reveals missing elements.
3
Correlate the omitted information with the specific components of a structured handoff.
The patient's past medical history and active comorbidities fall under the 'Patient Summary' component. Its omission directly caused the covering physician to unknowingly prescribe a contraindicated medication.
This confirms which systemic countermeasure was deficient.

Key Concept

In structured handoff protocols (e.g., I-PASS), the 'Patient Summary' must include a synthesis of the patient's active medical issues, baseline risk factors, and critical past medical history to prevent adverse events during unanticipated clinical scenarios.
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Topics

Transitions of Care and Handoff Protocols

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