What’s New in the Patient Safety World

December 2018

Handoffs Don’t Predict Everything



Arguably, the most important feature of the “signout” or handoff is the ability to anticipate events that might potentially occur on the next shift. But how good are we at anticipating actual events? A new study in an ICU setting provides some insight.


Dutra and colleagues in Brazil (Dutra 2018) analyzed 44 day-to-night handovers between intensivists in an ICU. They surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning.


Nighttime clinicians correctly identified only 53% of diagnoses and 40% of goals shortly after the handoff. The positive predictive value of both daytime and nighttime clinicians for anticipating clinical events at night was low (13% vs 17%). Daytime clinicians were more sensitive (65% vs 46%) but less specific (82% vs 91%) than nighttime clinicians in anticipating clinical events at night. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses.


The authors conclude that the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Furthermore, they suggest that handovers could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.


A previous study of pediatric resident handoffs (Borowitz 2008) showed similar problems in anticipating events. 31% of surveyed resident physicians indicated something happened while they were on call for which they were not adequately prepared. And in 82% of those instances, they indicated there was information they did not receive during sign-out that would have been helpful to them in caring for a patient overnight, And, of those, they indicated the situation should have been anticipated and discussed during sign-out in 82.5% of cases. Perhaps surprisingly, residents were no more likely to report events they were unprepared for when they were “cross-covering” at night than when they were members of the general pediatric ward team or if they had cared for the child previously.


Note that the Borowitz study was in the era before I-PASS became popular and successful as a format for handoffs. The I-PASS format stands for:

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver


The “S” for “situation awareness and contingency planning” obviously emphasizes the importance of anticipating things that might go wrong or events that might appear and stresses planning for contingencies.


Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics” and our What’s New in the Patient Safety World columns for June 2012 “I-PASS Results and Resources Now Available  and December 2014  I-PASS Passes the Testand the I-PASS website. I-PASS is really much more than a handoff format. It really is part of a culture of patient safety.



Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

August 28, 2007         Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

April 13, 2010             Update on Handoffs

July 12, 2011              Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011              Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success

October 2017              Joint Commission Sentinel Event Alert on Handoffs

October 30, 2018        Interhospital Transfers






Dutra M, Monteiro MV, Ribeiro KB, et al. A Study of Information Loss and Clinical Accuracy to Anticipate Events. Crit Care Med 2018; 46(11): 1717-1721




Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al: Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care 2008; 17: 6-10




I-PASS Study website.







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