11. Patient Handoffs

Background

Definition: the exchange of information during transfer of primary medical responsibility from one provider to another provider.

  • Increasing handoffs have been associated with poor communication leading to adverse events, medication errors, and worsened educational outcomes for medical students.
  • Safely performed handoffs provide opportunity for increased volume of exposure to clinical cases and management styles, an opportunity for “error-correction,” (double checking medication lists, problems lists, clinical reasoning), and opportunities to improve communication skills.

Strategies

Standardized mnemonics (e.g. I-PASS) have been shown to reduce medical errors and preventable adverse events without negative effects on workflow.

  • I – illness severity
  • P – patient summary
  • A – action list
  • S – situation awareness
  • S – synthesis by receiver

Commonly observed mistakes in sign-out:

  • Lack of clarity in anticipating problems (e.g. plan for broadening antibiotics).
  • Missing baseline mental status, abdominal exam, joint exam, etc.
  • Patient location, code status and/or medication list are not up-to-date.
  • “Nothing-to-do” or “NTD” listed on the sign-out but patient has “to-dos”.
  • Poor feedback by all parties about quality (or lack of quality) surrounding patient handoffs.

Tips:

  • Prioritize the sickest patients first.
  • Exchange of information should be face-to-face.
  • Make sure one designated person is responsible for updating sign-out (resident vs. intern).
  • Sign out in a quiet location with minimal interruptions, this should ideally occur in the same location and at the same time every day.
  • Both parties should have access to the electronic version of the handoff document.

 

Amy J. Starmer, M.D., M.P.H., et. al. for the I-PASS Study Group. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med; 371:1803-1812.

Arora, V., Kao, J., Lovinger, D., Seiden, S. C., & Meltzer, D. (2007). Medication discrepancies in resident sign-outs and their potential to harm. Journal of General Internal Medicine, 22(12), 1751-1755.

Cohen, M. D., & Hilligoss, P. B. (2010). The published literature on handoffs in hospitals: Deficiencies identified in an extensive review. Quality & Safety in Health Care, doi:10.1136/qshc.2009.033480

Vidyarthi, A. R., Arora, V., Schnipper, J. L., Wall, S. D., & Wachter, R. M. (2006). Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. Journal of Hospital Medicine : An Official Publication of the Society of Hospital Medicine, 1(4), 257-266. doi:10.1002/jhm.10