Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

Handoffs and Medication Errors: A Community Hospital Case Study

Alina M. Chircu
Bentley University
achircu@bentley.edu

Janis L. Gogan
Bentley University
jgogan@bentley.edu

Abstract
In hospitals, a handoff occurs when responsibility
for care of a patient is transferred to another
caregiver, along with information about the patients
condition, treatment plans, and orders. Prior studies
report that flawed handoffs contribute to adverse
events, but few studies have closely analyzed this from
an information processing perspective. We report on a
case study of medication administration processes and
related information quality issues associated with
handoffs in one hospital. Applying an interdisciplinary
lens (informed by prior work on health care quality,
process management, and accounting information
systems) this case study reveals evidence that handoffs
both contribute to process and data flaws and can
help reveal and correct prior errors. Our findings
highlight the importance of designing clinical systems
and processes that systematically prevent threats to
the validity, accuracy, completeness, and timeliness of
clinical data and that use handoffs to detect and
correct these four types of errors.

1. Introduction
Prior research finds that flawed handoffs
contribute to adverse events (patient discomfort, harm,
or death) in hospital settings. A handoff occurs when
responsibility for care of a patient is transferred to
another care-giver, along with information about the
patients condition, treatment plans, and orders.
Handoffs take place when the patient is admitted to
hospital, is moved from one unit to another, such as
from the emergency department or intensive care unit
to surgery, or is discharged. Handoffs also occur when
nurses or doctors change shifts, attending physicians
consult with specialists, or whenever data, information
or clinical judgments about specific patients are
communicated among clinicians (doctors, physician
assistants, nurses), pharmacists, or laboratory

Ryan J. Baxter
Bentley University
rbaxter@bentley.edu

Scott R. Boss
Bentley University
sboss@bentley.edu

technicians. Thus, a patient handoff serves several

functions:
Transfer of Responsibility for patient care: passed
from one clinician or clinical team to another.
Transfer of Data: pertinent data about patient
(age, blood type, etc.), his condition (symptoms,
vital signs), test results, and procedures
performed -- are transferred via speech, paper, or
information system (often via two or three of
these media).
Transfer of Information: Information (as opposed
to specific facts) regarding caregiver plans for
tests and/or procedures to be performed is
conveyed via paper form or a clinical information
system.
Conveyance of Clinical Judgment: Assessments
of patient condition, prognosis, and other aspects
are conveyed, usually via speech.
Understanding how flawed handoffs lead to
adverse events is important for designing better
processes and clinical information systems, and
minimize preventable adverse events.
In this paper, we focus on how handoffs affect a
specific type of adverse event: medication errors. The
Institute of Medicine [4] reported that about 400,000
preventable medication-related injuries occurred in
US hospitals in 2006. Reasons include drug
interactions, allergies, similar labels on dissimilar
products, confusion about product names, and
miscommunication between clinicians and patients or
pharmacists and among clinicians (e.g., physician to
physician, physician to nurse). Computerized provider
order entry (CPOE) and electronic medication
administration records (EMAR) are promoted as
systems that help reduce medication errors. Yet,
despite the benefits, CPOE systems reportedly also
cause or propagate medication errors [25]. In this
paper we examine how handoffs cause medication
errors and how handoffs help detect erroneous
information caused by previous process steps and stop
that information from being used in subsequent steps.
We examined evidence gathered in a case study at a

1530-1605/11 $26.00 2011 IEEE

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

community hospital as it prepared to roll out CPOE,

EMAR, and other software applications aimed at
improving the efficiency and quality of patient care.
We asked clinicians, pharmacists, members of the
executive team (CEO, COO, CNO, CMO, CIO) and
administrators to reflect on medication administration
challenges and issues. Specifically, we sought answers
to three research questions:
1. In reflecting on medication administration
processes, what handoff challenges do
administrators and clinicians identify? Which
challenges involve the data, information or
judgments that are conveyed, and which involve
the medium/media by which these are conveyed
(speech, paper, system or some combination of
these)?
2. How do effective handoffs detect prior mistakes,
thus helping to prevent medication errors?
3. Recognizing that clinical activities take place
within a complex, dynamic institutional context,
how do specific contextual aspects affect handoffs
and related data, information and judgments?

We applied an interdisciplinary lens, drawing on

prior research in health care quality, process
management, and accounting control theory, which
are reviewed next.

education emphasizes a patient- and process-focused

approach [32]. Since nurses administer medications,
they are the last line of defense, so training
emphasizes information verification; nurses are
expected to question doctors orders before carrying
them out if they suspect that the orders contain
incorrect information.
Although promising, some proposed process
improvement remedies may not be appropriate for all
clinical situation, due to high staff turnover [10],
ambiguous patient information [30], and treatment
diversity (different medical decisions, information and
handoff tasks required for each patient).
Improvements that entail standardized communication
may result in errors if forms do not completely capture
all information required for each specific handoff
type, or if caring for a particular patient requires
information that is not usually transmitted during a
normal handoff. Even where standards exist,
distractions and competing priorities may lead
clinicians to skip a check or overlook data revealed in
a check. Also, nurses may not always voice their
concerns, either because of low self-efficacy or other
reasons related to the higher status accorded doctors.
Some researchers contend that standardization may be
undesirable; they argue that the inherently
unstructured and ambiguous nature of a handoff
interaction makes it valuable for accurate information
recording, analysis, and trust building among medical
providers [30].

2.1. Prior research on handoffs

2.2. Conceptual lenses for this investigation

Flawed handoffs are implicated in many adverse

events, such as medication errors that result in patient
discomfort, injury, or death, delayed procedures (such
as medication administration and transplants), patient
dissatisfaction, and provider concerns about their
ability to provide adequate care [5, 10, 23, 30, 34].
Thus, improving handoff processes is seen as a key to
improving health care quality [3, 30]. Guidelines
issued by JCAHO (Joint Commission on
Accreditation of Healthcare Organizations) [19] aim
to reduce miscommunication during handoffs.
Proposed solutions include standardizing handoff
processes (by establishing clear rules) and
communication (by using standard written or
computerized forms and maps and verbal protocols),
avoiding interruptions, focusing on patients,
collaborating with other providers involved in the
handoff, and handoff-specific training [3, 7, 10, 27,
29, 37, 34]. Some proposed remedies are influenced
by studies of highly reliable handoff processes in
contexts such as aviation and racing [10]; others are
grounded in clinical practice. For example, nursing

Hospitalized patients usually receive medications

from nurses, who are trained to attend to the five
rights (right patient, drug, time, dose, and route of
administration) [12]. Still, medication errors are a
persistent problem [1, 24]. Information transfer during
handoffs (from patient to nurse, doctor to pharmacy,
pharmacy to doctor and nurse, and nurse to patient) is
a significant cause of medication errors [16].One
study reported that admission medication errors
occurred in 26% of cases for prescriptions and 33%
for
over-the-counter
medications.
Discharge
medication errors occurred in 19% of cases [6].
Many errors can occur before the actual
medication administration (the final handoff from
nurse to patient), due to flaws in previous activities -including previous handoffs. Thus, we propose that
understanding the causes of medication errors requires
adopting an end-to-end view of the entire care process
[8], for which a business process management (BPM)
lens [26] is appropriate. BPM, a methodology for
managing, improving and controlling processes, has
its roots in quality management, six sigma, process

2. Theory

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

improvement and reengineering [26]. Other

engineering and design disciplines -- such as systems
engineering, human factors and quality engineering -have also been utilized in patient safety studies [9,
13]. These approaches center on the work systems of
medical professionals and their impact on care
processes and patient outcomes [9]. For our study, we
selected BPM because, as explained below, it is
particularly well suited to an end-to-end, crossfunctional perspective, classifying activities for
improvement, and defining the care process all
important elements in understanding handoffs.
First, BPM suggests that improving handoffs
without considering the entire cross-functional care
process (across various departments and job roles)
may only lead to local optimization. Although process
methodologies and tools such as Six Sigma, Lean, and
failure modes and effects analysis (FMEA) have been
used to analyze and improve medical handoffs [6, 10,
28, 34], the focus has been primarily on the handoffs
themselves, rather than on end-to-end care processes.
For example, an improvement such as avoiding
interruptions may be difficult to implement without
adopting a full process view, with potential
ramifications across an entire hospitals operating
procedures and physical set-up. Also, collaboration
among providers during handoffs may be difficult if
they do not have a clear view of the end-to-end crossfunctional care process [27].
Second, BPM enables the classification of
handoff activities as value added, non-value-added,
and control, and encourages the elimination of nonvalue added steps. Thus handoff improvement efforts
should focus on value-added and control aspects ,
such as clarifying ambiguous information and
catching errors made previously [30], rather than
considering handoffs as non-value-added steps to be
eliminated or automated. Indeed, studies report that
handoff automation through CPOE systems
contributes to the propagation of medication-related
errors made in previous care activities [25, 31].
Third, BPM provides tools for identifying clinical
process suppliers and customers (and their
respective requirements and constraints), and for
analyzing handoffs as critical internal process
interfaces, for which senders and recipients of
information and their needs can be defined and control
points established.
Through application of a BPM lens in previous
studies [6, 8] we identify several end-to-end process
activities relevant to medication administration (See
Table 1). It is important to note that while most
studies limit the term handoff to situations when a
clinician or clinical team conveys responsibility, data,
information, and judgments to another clinician or

team, other studies take a broader view of the entities

involved. We include the patient as an active
participant in some (not all) handoffs. For example, an
incapacitated patient cannot take any responsibility for
his/her care, but a mother who has just given birth
may be quite an active partner in her care.
The patient care process presented in Table 1
usually includes many iterations between various
process steps for verification or clarification, parallel
activities, and sometimes partial duplication of
information [6]. During each handoff, information is
needed by participants. The clinician (physician,
intern, resident, specialist, PA, or nurse) who is
handing off the patient is an important information
source; others include the patient, his/her family,
pharmacy, laboratories, electronic monitoring devices,
an electronic health record (EHR), and other clinical
applications and databases. Information is conveyed
via speech, paper, and/or system often via more than
one medium simultaneously. Handoffs also produce
new information which is stored in clinicians heads,
on paper, and/or in a system. The quality of
information remains a significant problem.
Table 1. Medication-related handoffs (H) in
hospital patient care processes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Admission
Nurse documents existing medication list, if any, from
patient conversation (H)
Medication list is forwarded to pharmacist (H)
Pharmacist creates medication administration record
(MAR)
MAR is forwarded to other providers (nurse, doctor) (H)
Hospitalization
Doctor prescribes, changes or discontinues medications
Medication order is forwarded to pharmacy (H)
Pharmacist verifies and approves order and updates (MAR)
MAR is forwarded to other providers (nurse, doctor) (H)
Nurse retrieves medication (usually from floor-specific
medication cabinet or from pharmacy if not available) ( H)
Nurse administers medication (H)
Discharge
Doctor creates discharge prescription
Nurse educates patient (H)
Hospital forwards medication list and discharge summary
to follow-up provider (if any) (H)

To better understand the quality of information

transfer in handoffs, we propose using an information
quality lens. Accountants have long employed various
techniques to identify and address information quality
issues in transaction processing systems and related
business processes through which financial data flow
[14, 22, 36]. Auditors help to verify that information
quality is assured throughout a process and in related
systems and databases [18, 20]. Their aim is to ensure
that
financial
transaction
data
exhibits
representational fairness, consisting of the traits of
validity (data describes an event which was properly
authorized and actually occurred), accuracy (data
correctly describes relevant aspects of the event),

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

completeness (a record is captured for every relevant

event), and timeliness (available when needed) [2]. A
false invoice or payment to a fictitious recipient would
fail to pass a validity test; the recorded transaction was
not authorized. If the record of an event is incorrect
(such as indicating that 1000 products were sold when
the correct number is 100, or that a product was sold
for $100 versus the correct price of $200), the record
fails the accuracy test. If no record was made of an
authorized transaction that took place, completeness1is
violated. If a decision-maker or process participant
does not have access to information when it is needed,
timeliness is violated.
These data quality traits aptly apply to physicians
orders and data describing administered medications,
tests, and procedures. Errors identified in previous
studies [5] can thus be classified as compromising
validity (unauthorized drug, additional dose, incorrect
route), accuracy (incorrect dose), completeness
(failure to administer dose) and timeliness (delay in
administering dose). The benefit of using this
perspective is that best practices for preventing,
detecting and correcting information quality problems
in other settings can be used to analyze clinical
processes and suggest improvements.

3. Case methodology and findings

Sections 3.1, 3.2 and 3.3, respectively, describe
our methodology, the case context, and our findings.

3.1. Methodology
A case study was conducted at Community
Hospital (CH), located in a U.S. metropolitan area.
Data were gathered by means of on-site semistructured interviews conducted with 16 individuals in
the fall of 2009: the Chief Executive Officer,
Executive Vice President, Senior VP/Chief Operating
Officer, Chief Information Officer and a project leader
in Clinical Informatics, Pharmacy Director, a
Pharmacist, VP of Medical Affairs, Hospitalist
Program Medical Director, Division of Geriatrics
Chief, Chief Nursing Officer, two other nurse
managers (Director, Outcomes; Senior Director, Risk
Management), two floor nurses, and a physicians
assistant. Interviewees were asked to describe CHs
efforts to improve patient safety in general and in
1

Accountants consider validity, accuracy, completeness, and

timeliness, essential data quality dimensions for financial records.
Other desirable qualities (identified by the Financial Accounting
Standards Board) include understandability, decision usefulness,
verifiability, neutrality, predictive value, feedback value,
comparability, and materiality.

medication administration processes. Other questions

related to individuals roles (e.g., the CEO discussed
strategic priorities, including patient safety initiatives;
the CIO discussed IS issues and project priorities).
Interviews of 30 to 60 minutes in length were
recorded and professionally transcribed. The research
team toured a medical/surgical unit and examined
various internal hospital reports. We prepared a
repository of key documents, including these reports
and other information provided on the hospitals web
site and in news accounts.
Analysis followed the constant-comparative
method [35]. Factual coding was done on the
interview transcripts and other documents, to capture a
timeline of key events and descriptive data about CH,
its governance and descriptions of critical incidents. In
a comparative coding step we classified interview
segments into themes previously identified in the
literature (e.g., strategic priorities, regulatory and
organizational challenges) and in our broader study of
data and process quality issues in health care. In an
open coding step we identified themes that were not
previously anticipated, such as a theme about
educating rather than punishing individuals who
make medication errors. Factual, comparative, and
open codes derived from the interview data were
compared across interviewees and also (where
possible) triangulated against information provided
from other sources, such as hospital planning
documents and quality reports. Through an iterative
process of interpretation [33] we considered
relationships among themes and their deeper meaning.
For example, we explored relationships among the
hospitals capacity constraints, handoff information
media, and medication errors.

3.2. Case context: Community Hospital

CH, formed in a merger of two hospitals, is the
third largest hospital in its US metropolitan area,
behind a prominent tertiary care hospital and another
large community hospital. It serves both a large
Medicaid (low-income) population and a large
Medicare (geriatric) population, and offers a full range
of medical and surgical care, substance abuse
treatment, psychiatric care, and rehabilitation services.
At the time of our interviews several major
projects were underway to modernize and expand
their facilities, and the CEO hoped to win state
approval to increase their medical/surgical capacity.
He and other clinical and administrative leaders
mentioned insufficient capacity as a major
institutional pressure.
The CEO emphasized the hospitals commitment
to measuring and monitoring clinical processes and

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

outcomes. For example, when data revealed that a

number of joint replacement patients suffered postsurgical pulmonary embolisms, a team did a rootcause analysis and proposed changes which were
institutionalized, leading to a substantial reduction in
this condition. A similar approach was taken to reduce
other hospital-acquired conditions, such as infections.
Each month the executive team, top clinical leaders,
and board of directors receive reports on key metrics
and discuss progress or setbacks in these clinical
quality indicators. The hospital also participates in a
benchmarking activity sponsored by a hospital
consortium, of which CH is a member. CHs
information systems organization was preparing to test
and launch several major clinical systems over the
next few years, including CPOE and EMAR, to be
implemented in phases in various hospital
departments.

3.3. Case findings

We elicited interviewees views regarding
obstacles to perfect medication administration. We
learned of ongoing challenges in how CH attempts to
ensure that information about patients and ordered and
administered medications is valid, accurate, complete,
and timely. Interviewees discussed various challenges
and noted that clinical contexts vary in complexity,
number of clinicians and hospital units involved, and
other aspects. Herein we describe a relatively simple
medication administration scenario in a non-urgent
care situation, from patient admission through
discharge. Table 2 highlights key value-added
activities, outputs, and handoffs between clinicians
and systems. Using the handoffs (lettered for
reference) in Table 2, we identify potential risks in
Table 3 and mitigating controls in Table 4.
The Chief Nursing Officer stated that nurses are
supposed to check that the medication administration
record (MAR) includes the patients weight, and to
flag illegible orders before they are sent to the
pharmacy. However, This doesnt always happen:
If (nurses) dont pay attention the pharmacist has
to deal with an illegible order. On average, nearly
125 orders per day need to be verified (of about 600
orders per day total). Think of all that work, to have
someone do that!
While nurses play a pivotal role in ensuring that
the right meds are given to the right patient,
physicians also mentioned some close calls. One
involved a clerical error: The wrong name was
stamped on the order sheet. (which was) supposed
to be pre-stamped with the name of the patient A
secretary (had) put the order sheet back in the wrong
chart. It was one of the few double rooms, and she put

it in the chart of the patients roommate. CH only

has a few double rooms (most are singles), so this type
of error is infrequent. Nurses mentioned another issue:
multiple patients with the same name on the unit
(common names such as Smith or members of a
family involved in the same accident for which they
are being treated): Ive had three Smiths on the floor
at the same time We put stickers on the door, the
chart, and in the other room: Caution: Patient has
similar name.
Table 2. Value-added activities, outputs, and
handoffs in medication administration
Role
Output(s)(it
alics)

Value-added activities (numbered)

Handoff description (italicized, lettered)

Nurse
Intake info

1. Interview patient and record patient history

A. Handoff of patient and history data to doctor.

Doctor
Orders

2. Examine patient: Repeat some questions asked

by intake nurse. Order X-rays, medication, etc
B. Handoff of patient, intake information,
doctors orders to PA.

Physician
assistant
Reconciliati
on

3. Medication reconciliation: Interview patient,

record on paper form. Check what drugs patient
is taking, compatibility with ordered meds,
whether same/equivalent drugs are in formulary.
C. Give form to unit secretary

Unit
secretary
Fax receipt

No value added activities.

D. Fax order to pharmacy

Pharmacist
Medication
orders in
system

4. Review Order
5. Enter into pharmacy system
6. Resolve potential drug interactions along with
other system-generated warnings
E. Submit finalized orders into Pharmacy System
(order data will be integrated with patient
billing data; this financial process not
addressed here)

Pharmacy
system
MAR
Hospital
personnel
Nurse
MAR
record

Doctor
Rx
Nurse
Rx
Hospital
personnel
Medication
list

8. Create medication administration record

(MAR)
F.
Send MAR to computerized medication
cabinet
9. No value added activity
G. Paper MAR delivered to nurse server
cabinet
10. Retrieve MAR
11. Record withdrawal from computerized
medication cabinet (which also records
withdrawal) or other source (e.g., refrigerator)
12. Administer medication following five rights
13. Record time of medication administration
H. Change-of-shift bedside reporting
14. Create discharge prescription (Rx)
I. Give information to nurse
15. Educate patient
J. Hand deliver paper forms (if any) to patient
16. No value added activities.
K. Send to follow-up provider]

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

A Failure to capture patient data: A, C; could also affect T

B

Failure to capture patient data: A, C; could also affect T

Patient feigns great pain in attempt to get a narcotic: V

Failure to capture patient data: A, C; could also affect T

Patient may not report every drug he is currently taking: C
Patient reports wrong drug (Xanax instead of Zantac): A
You may be taking something for your blood pressure that
the institution doesnt carry. We have to substitute what we
carry here, or ask you [or family member] to bring your
own pill.

D Nurse says a distracted secretary may fail to fax order: C, T

The secretary might be taking 10 phone calls
E

Data-entry errors by pharmacist: A

Sometimes its a pharmacy mistake They print it at 100
even though she clearly wrote 10.
Ignoring automated error alerts: V
Automatic warnings and alerts come up so often that theyre
almost always overridden (due to) alert fatigue.
Discontinuing medications: V
There have been times when Ive discontinued a medication
and it wasnt caught by the pharmacy.
Distractions and interruptions in the pharmacy: V, A, T
The requirement is that they should be in an uninterruptible
area, uncluttered, clean, quiet. Not paying attention when
they sign off is what the pharmacists will tell you is their
number one for getting errors; they are distracted. They
are required to answer phones, get up and open doors..now
youve got pharmacists saying Were distracted; its a
chronic distraction in our area.

F No risks identified by participants

G No risks identified by participants
H Interruptions and distractions: V, A, T
A phone call, a code, a patient falls, a doctor asks you to
help with something. Signs say Quiet Zone but
Not wasting of wrong medication if recognized before
administration, must be wasted to prevent billing or
clinical errors: V, A
Packaging confusion. If doctor orders 0.5 mg, but drug
comes only in 1 mg size and remainder of dose is not
wasted, patient record will erroneously show 1 mg received
or patient might suffer harm from overdose: V, A
[Wasting] requires two nurses. The second nurse has to
bioID in [to medication cabinet], and you go through the
steps to waste it. That can slow you down. You have to
count everything thats left. Any narcotic, every time.
Discontinue/increase/decrease dosages: When new drugs are
ordered, medication reconciliation has to take place, and
when dosage changes, PA has to write on form that old
dosage is discontinued and list new dosage on a separate
line. Compliance with this rule is not 100%. V, A, C
Miscommunication after a shift change, resulting in errors in
medication administration: V, A, C, T
I No risks identified by participants
J Medication Reconciliation at Discharge: A
Now you go home and unless you are careful, you start
taking your old blood pressure pill, plus the one we gave
you here, because were not careful when writing your
discharge instructions and reconciling that process
K No risks identified by participants

Table 4. Medication administration controls

Handoff

Handoff

Table 3. Handoff risks identified

Risks and information attributes potentially affected:
V=validity, A= Accuracy, C= Completeness,
T=Timeliness
Sample supporting interviewee quotations (italicized)

Current medication administration process controls

Quotation example(s)(italicized)

A If information is incomplete in one step, subsequent valueB added steps may note this and retrace the process or
C follow-up with those responsible for completing previous
D steps.
There's a lot of back and forth that goes on between the
pharmacist and physicians, as far as verification of the
order.
If handwritten order is illegible or partially legible at any
stage until entered into the system, clarification is needed.
If you cant read it your role is to stop and call the
provider.
E Automated error alerts
F Quiet zone signage for pharmacy and nursing
H
H Nurse should follow up if alerted to a medication
administration order that extends beyond 2 hours.
Change-of-shift bedside reporting, consistent with
guidelines recently promulgated by JCAHO.
Now we report right inside the patients room. During the
handoff, we actually go over everything thats going on
with the patient. What IVs are hanging? What meds? We
do a full thorough review. Thats the shift to shift handoff.
At changes of shift, oncoming nurse also performs redlining procedure to verify all information.
You need to get a report from the other nurse, the hand off.
(Nurse) double checks [prior shifts] orders on every
patient to make sure that every order was in fact taken off.
I check, I initial, and put a red line around the entire
order set that says this is good Its how nurses hand
off communication, how we collaborate to make sure the
patient got the right care.

We also note another important process variation:

when a patient is treated in the ED, pharmacists are
less involved in reviewing medications (since meds
may need to be administered immediately). ED nurses
are less focused on documenting medication
administration, although the smart medication cabinet
helps. Pharmacy will know that patient; at least [the
medication cabinet] will say for this patient, this was
pulled out ... theres that amount of documentation,
but no pharmacy is verifying that order.
Interviewees mentioned that hospital capacity
issues (more than half of the time, inpatient units are
at full capacity) lead to handoff errors. On the day we
visited, the medical/surgical floor was at full capacity;
more than 20 patients were temporarily bedded in the
ED. This creates problems for the ED and handoff
challenges for the medical/surgical floor. A paper
chart is started for the patient while in the ED. So long
as this chart accompanies the patient to the floor,
information is not lost (however, timeliness is
threatened when the information is not in the system,
and also the chart sometimes does get misplaced). A
doctor connected the dots among capacity constraints,
room assignments, and medication administration

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

errors: We had three Smiths; two were across the

hall from each other. Thats something that might be
approached in bed assignment. But when you are
boarding people in the hall its hard to be fussy about
where to put your patients. That introduces an
opportunity for error.
These comments highlight the necessity of
considering the broader context of care. For example,
at CH it seems that extra vigilance is required to
ensure both information quality and care quality
during transitions of care, especially between the ED
and the inpatient units
We identified many points during hospitalization
when errors can occur and distort information
subsequently needed during a handoff. Like in other
hospitals, many CH interviewees believed CPOE and
EMAR will reduce errors. The Chief Nursing Officer
stated that CPOE will put the right controls into
place, the right rules so those things can be
corrected. Rollout was expected to start a few
months after our interviews, with implementation to
be completed in 2011. One doctor noted that without
CPOE, illegible handwriting or missing data requires
that the pharmacist go back to the individual who
wrote that. Other expected benefits included
improved completeness and timeliness: if
[medications] are ordered post-op, youll have that
electronic record of when it was administered in OR,
so that you can make sure that if you are in a Q4 hour
schedule or a Q6 hour schedule, youre hitting those
times as required.
Despite the expected benefits, some interviewees
felt that some of the process ills identified above
will not be cured by new systems. Several
interviewees were concerned that when CPOE is
implemented in their unit, a problem will arise
because the ED, ICU and surgical recovery units will
implement CPOE later: Patients moving from unit to
unit, what do we have to do when they are going from
electronic to paper and back to electronic? In and out
of the ICU, because the ICUs not coming up [not
going to be on the CPOE system yet], theres a lot of
stuff. Others expressed concern that alert fatigue
might occur in response to the CPOE system: In
computerization there's all these automatic warnings
and alerts that come up. They come up so often that
they're almost always overridden by the pharmacist
[] I think when we get it here it would be overridden
by the docs. Another issue identified in our
interviews concerned resident training: I hear that
[EMAR] doesn't work well in a teaching situation, if a
few residents are in a clinic, which is common.If
you the teacher in a residency program you want the
resident to document their thought process and how
they got to their conclusion and what they saw, and

that stuff isn't embedded in the EMAR. This is a

particularly important issue, since in our interviews
residents were often implicated in medication errors,
and an automated system seems to eliminate an
important control for detecting gaps in residents
knowledge. Lastly, interviewees suggested that CPOE
may introduce process changes that could increase
clinicians cognitive load and potentially lead to more
errors: A lot of things go on behind the scenes;
things that providers have to care about, that they
never even knew happened before.

4. Discussion and conclusions

Hospitals aim to provide safe, reliable, error-free
patient care. Handoffs need to convey valid, accurate,
complete and timely data, information and judgments.
Thus, those who design clinical processes and systems
need to focus on the conveyance of clinical data,
information and judgments in a manner similar to the
attention given financial transactions. Application of
the BPM and information quality lenses helped us to
identify potential errors of many types, as well as
opportunities to catch those errors in the end-to-end
patient care process.

4.1. Key findings and insights

Consistent with prior work, our study found that
handoffs give rise to errors which can cause patient
harm. Inherent in all handoffs is the potential to
communicate incorrect or incomplete information.
Our study findings confirm that information can be
distorted or lost because of misspelled orders, illegible
forms, facility limitations (patients bedded in
hallways), random circumstances (patients with
similar names), and technical limitations (some
departments not using automated systems). And, due
to limitations inherent to verbal and written media,
some clinical observations and judgments are
inevitably lost in translation between individuals
and across various media.
Our study also reveals that handoffs can reduce
patient harm by detecting errors committed in
previous clinical steps (possibly unrelated to the
handoff), or during a handoff. For example, the
recipient of conveyed data, such as a specialist
physician, may, by virtue of their knowledge or
expertise, connect the dots of evidence and decide to
order an additional test or change a treatment plan.
When a handoff succeeds in detecting prior mistakes,
it ensures that these mistakes will not affect
subsequent steps in the clinical process. Further, a
handoff recipient may notice that an ordered
medication could harm this patient, due to either

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

allergies, a dosage error in the prescription, or

interaction with other drugs. By questioning the
information conveyed in the handoff, this recipient
helps to detect a mistake and prevent its propagation.
We also find that patients are important sources of
information and may help catch errors.
Use of the BPM lens allowed us to identify
opportunities to reduce errors. For example,
distractions were repeatedly discussed as a problem
for pharmacists and nurses. This suggests that
hospitals need to redesign workspaces and processes
and redefine roles and responsibilities in order to
reduce distractions. Furthermore, use of the
accounting information systems lens helped us
identify specific threats to clinical information quality
(to validity, accuracy, completeness and timeliness).
Our recognition of accountants emphasis on
prevention, detection, and correction helped us
identify ways that hospitals can prevent, detect and
recover from clinical errors. For example, since our
respondents emphasized that it is not feasible to
eliminate all distractions, we conclude that, in addition
to taking steps to prevent medication errors, hospitals
should also implement stronger processes and systems
for detecting and correcting errors, especially in those
clinical contexts with high levels of interruptions.
We conclude that the BPM and accounting
information systems lenses are complementary
methodologies which hospitals can use to improve
medication administration process quality. We further
conclude that by looking holistically at end-to-end
clinical processes, hospitals can identify those patient
care situations that may require increased vigilance
and a higher level of error checking. For example, our
study finds that constrained capacity is a high-risk
condition that increases the opportunity for errors. As
increasing capacity in order to prevent overcrowding
is not always feasible, hospitals can minimize the risk
of errors by continuously monitoring patient demand
versus hospital capacity in order to detect potential
problems, and designing an action plan in order to
immediately correct capacity imbalances if they occur.
Information systems such as CPOE have the
opportunity to facilitate valid, accurate, complete and
timely transfer of data, information and clinical
judgments, but cannot be completely relied on to
prevent errors. Thus, one of the primary objectives of
systems designers should be to encourage clinicians to
think and be aware of potential breakdowns in the
information flow as well as the potential value-added
and control features of each information source. Some
of our interviewees comments implied that
automation reduces ones need to think. We conclude
that the implementation of an automated system

increases the need for clinician awareness to prevent

the propagation of errors.
Overall, our findings lead us to conclude that
clinicians and system designers need to be both nearsighted and far-sighted. They need to design
clinical processes and systems that systematically
prevent threats to the validity, accuracy, completeness
and timeliness of clinical data, and that use handoffs
to systematically detect and correct these four types of
errors. Designers of processes and systems need to
focus closely on fine details of the care process, the
data, information, and judgments needed during
handoffs,
and
specific
information
quality
requirements. They also need to step back and
consider how handoffs and related medication
administration processes are affected by the broader
institutional context and by interdependencies among
sub-processes (such as the relationship between the
billing system and the medication administration
system), choices made by suppliers and partners (such
as the pharmaceutical companies choices about
packaging and labeling), and resource constraints
(such as hospital bed shortages).

4.2. Contributions, limitations, and

suggestions
While prior studies emphasized provider-provider
handoffs, this case study examines these as well as
system-provider and patient-provider handoffs. By
using the BPM view we identified handoff
disadvantages and advantages in the end-to-end
patient care process. By applying the information
quality lens drawn from accounting, we examined
handoffs at a finer level of granularity. Our analysis of
medication administration processes at CH revealed
issues of validity, accuracy, completeness, and
timeliness in patient care handoffs. Future studies can
explore the feasibility of applying other techniques
from the discipline of accounting information systems,
particularly techniques that systematically assess the
adequacy of manual and automated preventive,
detective and corrective controls.
For practice, this study clarifies how patient care
handoffs both lead to medication errors and help to
reduce them. These observations can help hospital
administrators identify best practices and aid
improvement efforts. The study findings highlight
important handoff features that need to be considered
when designing and implementing clinical
information systems such as CPOE and EMAR. In
particular, our findings point out a possible unintended
consequence of automating medical processes:
clinicians may too readily accept information
conveyed by an automated system. While the use of

Proceedings of the 44th Hawaii International Conference on System Sciences - 2011

CPOE or EMAR helps protect clinical information

quality, errors made prior to transmission can still be
propagated if detective controls are not properly
implemented or error warnings are ignored. Clinical
information systems are not a panacea; they should be
designed and implemented with utmost care if patient
safety is to be assured. In particular, following the
BPM view we recommend that clinicians be made
more aware of the potential for medication
administration errors during the end-to-end patient
care process. Training should emphasize how flawed
patient handoffs lead to dangerous information errors,
how well designed and executed handoffs can bring
such errors to light, and how handoffs can reveal prior
clinical mistakes.
We conducted a single case study at one point in
time. A key strength of this research methodology is
that we were able to examine one aspect of clinical
care medication administration processes from
multiple conceptual angles and informed by multiple
participants. By triangulating our interview data
against other CH data sources (such as the CH annual
and quality reports and other documents), we were
able to paint a richer picture than can be obtained via
other methodologies. Through a process of data
comparison and interpretation, we were able to
connect the dots among issues, seeing for example
how the hospitals constrained capacity created a
challenging condition for effective patient handoffs
and medication administration. A limitation of our
single-case methodology is that we are not yet able to
generalize to a broader population. A next step would
be to conduct similar case studies at comparison
hospitals (community hospitals of similar size and
with similar patient populations) as well as at hospitals
which differ markedly on some dimensions (such as
much smaller rural community hospitals or much
larger tertiary-care teaching hospitals). Further
research can also gather longitudinal and crosssectional data about both manual and automated
medication administration and handoff processes.
Our study contributes to the healthcare IT
literature by investigating a key aspect of clinical care
handoffs and their impact on medication
administration processes, prior to a planned
implementation of new clinical information systems.
A recent meta-analysis of health information systems
impacts finds that experts consider healthcare IT to be
key to improving efficiency and quality of care [11].
However, introduction of a new system disrupts extant
work routines and may lead to clinical mistakes if
appropriate steps are not taken to insure successful
implementation [15]. Last, but not least, physicians
acceptance of the new IT system may depend more on
its perceived usefulness than on its ease of use [17].

Thus, understanding existing handoff processes, with

their advantages and disadvantages, can contribute to
more successful healthcare IT solutions.
This work also contributes to identifying
weaknesses and strengths of handoffs so that
ontologies for advanced integrated healthcare
solutions [21] that support improved data sharing and
higher quality outcomes can be further developed. In
looking at handoffs across the entire care process we
are exploring both the complexities, challenges, and
advances in sharing data, information and clinical
judgments between patients, physicians, nurses,
pharmacists, and others. These insights can enable
better pre- and post- IT implementation comparisons,
and promote future enhancements to current health
information systems evaluation frameworks [38].

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