September 30, 2008
Hot Topic: Handoffs
There has been a striking number of publications in the last 2 months about problems related to handoffs. That shouldn’t be surprising in and of itself since we know that problems related to faulty communication underlie many patient safety problems. It’s well known that problematic communication is a root cause in about 70% of all sentinel events in the Joint Commission Sentinel Event Database. Several of our previous columns have focused on communications and handoffs.
Separate studies coming out of Harvard and Yale provide real estimates of the frequency with which faulty handoffs result in both patient harm and inefficiencies and redundancies in care. Horwitz and colleagues (Horwitz 2008) at Yale did a prospective study in which they reviewed in detail both oral and written signouts and then reviewed patient cases to determine whether problems with care had occurred. Of 88 such signouts, problems were identified in 24 cases. This included adverse clinical consequences for 5 patients (delays in diagnosis or treatment) and 4 near-misses. Just as importantly, in 15 cases the care was either inefficient or resulted in duplicative efforts. They provide specific examples of some of the problems encountered. In many cases, the housestaff ended up spending much wasted time that could have been avoided by spending more time up front on a good handoff.
A somewhat similar study was done at the Massachusetts General Hospital (Kitch 2008). They surveyed medicine and surgery residents about events related to handoffs that had occurred in their most recent rotation. 58.3% reported that at least one patient had experienced minor harm and 12.3% reported at least one patient had experienced major harm. A third of the residents surveyed reported their overall experience with handoffs to be poor or only fair. By location, handoffs from the emergency department or from other hospitals were the most problematic. Though most of the handoffs were conducted face-to-face, they were seldom done under ideal circumstances. Almost half reported that handoffs seldom took place in a quiet, private setting and more than a third said that interruptions occurred during most handoffs. The average time spent on a signout was about 20 minutes plus another 20 minutes preparing for the signout. This study also provides some examples of the types of specific clinical information omitted during the signouts that might have been helpful.
We previously discussed many of the issues around handoffs in our February 26, 2008 Patient Safety Tip of the Week “Lardner 1996). Information at handoffs should be repeated by more than one method. For example, the communication may be written but then should be conveyed by a second method, such as a face-to-face verbal communication. Cues such as speech inflection and body language may convey important messages during such face-to-face communications, enhancing memory of the salient points. The verbal face-to-face contact also provides the opportunity for 2-way communication and feedback, both of which are essential in ensuring that both parties understand the information conveyed. Adding structure to written documents and defining what should be included in handoffs are very helpful. Hence, the popularity of techniques like SBAR (Situation-Background-Assessment-Recommendation). And eliminating unnecessary information may be very important. Lastly, training and education in handoffs should be a priority for organizations, as should providing adequate time for such handoffs. Since then we also came across a comprehensive internet-based bibliography on handoffs put together by Ingrid Philibert of the ACGME that provides a wealth of resources on handoffs primarily from the medical literature.”, including lessons learned from considerable research done in other industries (
Another recent paper by Berkenstadt et al (Berkenstadt 2008) used direct observations of critical care nursing handoffs to develop a handoff protocol and incorporation of handoff training into a simulation-based teamwork and communications workshop. The intervention resulted in improvement of communicating certain specific information during handoffs.
And from the surgical literature, Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention.
And lastly, a slightly different sort of handoff studied (Gandara 2008) involved the information about anticoagulation for treatment or prophylaxis of thromboembolic disease transmitted to subacute rehabilitation facilities on discharge from acute care hospitals. Only 45% of patients discharged on heparin (unfractionated or low-molecular weight heparin) and 16% of patients discharged on warfarin had all the required information in the discharge summary.
These papers all highlight the pressing need for organizations to develop structured tools for handoffs, whether they are paper-based or electronic, but that those tools must be used in conjunction with a verbal face-to-face handoff in an optimal setting to convey the most important information needed to care for patients. Review of your handoff experiences, like Yale and the MGH did, may highlight for you the current weaknesses in your system and suggest specific measures you need to include in the training programs you set up to improve handoff skills, whether they are aimed at medical staff, housestaff, nursing staff, or any other members of the healthcare team. The time spent in doing handoffs well is more than made up by avoiding duplication and other inefficiencies and obviously leads to better and safer patient care.
Update: see also Our December 2008 What’s New in the Patient Safety World column “Another Good Paper on Handoffs” and our June 30, 2009 Patient Safety Tip of the Week “iSoBAR: Australian Clinical Handoffs/Handovers” and our April 13, 2010 Patient Safety Tip of the Week “Update on Handoffs”.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of Inadequate Sign-out for Patient Care. Arch Intern Med. 2008;168(16):1755-1760.
Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG. Handoffs Causing Patient Harm: A Survey of Medical and Surgical Housestaff. The Joint Commission Journal on Quality and Patient Safety 2008; 34: 563-570
Lardner R. Offshore Technology Report – OTO 96 003. Effective Shift Handover – A Literature Review. Health & Safety Executive, 1996
Philibert I. Selected Articles on the Patient Hand-off Compiled by Ingrid Philibert, Updated December 2007
Berkenstadt H, Haviv Y, Tuval A, Shemesh Y, Megrill A, Perry A. Rubin O, Ziv A. Improving Handoff Communications in Critical Care: Utilizing Simulation-Based Training Toward Process Improvement in Managing Patient Risk. Chest 2008; 134:158–162
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Gandara E, Moniz TT, Ungar J, Lee J, Chan-Macrae M, O'Malley T, Schnipper JL. Deficits in Discharge Documentation in Patients Transferred to Rehabilitation Facilities on Anticoagulation: Results of a Systemwide Evaluation.The Joint Commission Journal on Quality and Patient Safety 2008; 34: 460-463