Remember a game you probably played as a kid – you’d start with a brief story and say “Psst! Pass it on.” By the time the story had been “passed on” to several people it may bear little semblance to the original story. Key elements get omitted and sometimes new irrelevant information or even erroneous information gets added. The same thing happens with verbal communications in real life, even in healthcare. A study on handoffs demonstrated that verbal-only handoffs are rife with errors (Bhabra 2007). The investigators constructed a simulated handoff scenario on 12 fictional patients with 20 data points per patient and then randomized residents to participate in handoffs that were either (1) purely verbal (2) verbal with the receiver taking notes or (3) typed on a formal sheet. In the verbal-only group, by 5 handoffs only 2.5% of the data points were retained. In the note-taking group 85% of data points were retained and in the formal typed sheet handoff 99% were retained after 5 handoffs. The lesson: verbal-only handoffs are very dangerous!
Note that a previous study on nursing handoffs (Pothier et al 2005) showed that pure verbal handoffs and note-taking style handoffs had high rates of data loss but that when a typed sheet was included with the verbal handoff, data loss was minimal.
The Royal College of Physicians (England) recently published a toolkit for handoffs (or “handovers” as they are called in England) that relied heavily on the Bhabra study. They call for formalization and standardization of the handoff process, recognizing though the need to tailor the process to unit/local needs. They stress the multiprofessional nature of many handoffs and stress that the handoff process should have leadership (and not necessarily medical staff). Part of the handoff is clearly delineating the change in responsibility that is occurring. Prioritization of needs and risks is important and they suggest a green-amber-red color scheme to denote the varying levels of patient risk. An important part of the process is monitoring the effectiveness of handoffs. They suggest auditing checklists and/or other written or computerized tools, getting feedback from participants, assessing efficiency (eg. LOS), and assessing patient satisfaction. They also provide some templates, a handover proceedings sheet and an out-of-hours-handover template.
Importantly, the RCP toolkit emphasizes that the handoff must be “owned” by the organization. That is, the organization (hospital, facility, or larger organization) must ensure that the systems and conditions are in place to allow effective handoff. Those include overlapping duty times (shifts), rationalization of shift patterns of different roles (doctors and nurses), and provision of an appropriate environment. How many of you can say with conviction that you provide all those?
A recent observational study of handoffs in the emergency department (Maughan 2011) confirmed a high number of omissions and errors. The authors observed over a hundred handoffs, involving almost 1000 patients. Typical handoffs between attending physicians included about 10 patients and lasted about 15 minutes (for residents the numbers were slightly smaller). They also had some “team” handoffs, though nursing was not included in any of their handoffs. Most of the handoffs occurred in a central ED area away from patient rooms. Incoming physicians referenced the EMR in 72% of the handoffs and written notes in 43%. Incoming physicians asked questions in about 40% of handoffs. The incoming physician repeated details of the handoff in only 6% of cases. The outgoing physician reported incorrect information in 0.7% of handoffs but the information was corrected prior to completion in all cases. In 0.3% of cases the incoming physician corrected the outgoing physician based on information available in the EMR.
Omissions in the physical examination occurred in 45% of handoffs and omissions in laboratory data occurred in 29%. Errors in the physical examination occurred in 13% and lab errors in 3.7% of handoffs. Longer average handoff duration per patient was associated with more errors. Longer ED lengths of stay were associated with fewer errors but more omissions. When the incoming physician used the EMR or took written notes there were fewer errors.
One very interesting finding was that “team” handoffs were somewhat more prone to errors of laboratory information. Also the number of laboratory errors was proportional to the ED length of stay.
Longer handoff duration per patient was also associated with more omissions. That sounds counterintuitive but the authors speculate that the overall duration might be increased by discussion of a few patients, with less time spent on the remaining patients perhaps leading to more omissions. The authors did note that about one interruption occurred per handoff but did not correlate these with errors or omissions.
The authors cite that error-reducing tools, like reference to the EMR or written notes, was useful in reducing errors but other error-reducing tools, like readback, were seldom used. They also noted that discussion of the patients’ outpatient medications seldom took place, suggesting this is an area for potential improvement.
In a recent letter to the editor (Ross 2011) a simple tool for handoffs in the ED was presented. The incoming physician serves as the scribe as the patient is presented. The form includes not only patient identifiers and assessment, but also notes pending studies and potential dispositions. Implementation of that form was well-received by emergency medicine residents, though formal impact on errors was not measured.
A recent article on fatigue in surgical residents (Kahol 2011) noted that, though the residents had considerable deficits in cognition and performance on a laparoscopic surgery simulator, they actually took considerably less time to complete their tasks post-call. The authors note that there may be a tendency to complete tasks in a rapid manner at the end of call, accepting an increased error rate, and speculate that this may have an untoward effect on handoffs.
Our April 13, 2010 Patient Safety Tip of the Week “Update on Handoffs” highlighted some statistics on the impact of faulty communication and handoffs on malpractice claims. There we noted an article by Cheung et al (Cheung et al 2010) that had some good advice regarding strategies to improve ED handoffs. Firstly, reduce the number of unnecessary handoffs, for example by scheduling overlapping shifts or protecting the departing physician from new patients toward the end of a shift (but beware of the unintended consequence of pushing the patient through the system too rapidly). Do the handoffs in a quiet, dedicated space to minimize distractions, leaving adequate time for discussion and questions. Balance completeness with succinctness in the handoff (if too much information is conveyed, the critical elements are often lost among the irrelevant ones). Prioritize patients who need to be seen first and communicate all outstanding issues (labs, radiology, consultations, etc.). Be sure to spell out authority issues (eg. when a consultant will be determining disposition of the patient) and let all the ED staff know that a transition of care has occurred.
One of the collaborative projects of the Joint Commission Center For Transforming Healthcare is on Hand-off Communications. The storyboards for that project detail many of the root causes identified from fumbled handoffs and provide useful examples of interventions to help avoid them. The focus needs to be as much or more on system issues than on individual issues. While they do talk about structured tools and using technology to improve the handoff process, they especially focus on the need to inculcate the importance of communication into the culture of the organization, establish workspace and conditions conducive to good handoffs, and intergrate the handoff process into the workflows of healthcare workers. They use the acronym SHARE (S standardize critical content, H hardwire within your system, A allow opportunity to ask questions, R reinforce quality and measurement, E educate and coach) to help all remember key elements of successful handoffs.
The February 2010 issue of Joint Commission Journal on Quality and Patient Safety was a theme issue on handoffs. One paper (Anderson 2010) demonstrated how standardized EMR-based handoff software improved data accuracy and content consistency, was well-received by users, and improved perceptions of handoff-related patient safety, quality, and efficiency. A second (Bernstein 2010) showed that integration of signout notes into an EMR also led to an improvement in physician workflow. A third (Patterson 2010) dealt with the complex problem of measuring the effectiveness of handoffs.
While SBAR is probably the structured format used most widely for handoffs in healthcare, a variety of different formats are available. An article in Hospitals & Health Systems a couple years ago (Runy 2008) summarized some of the structured techniques used in handoffs, including not only SBAR but also “I PASS the BATON”, and the US Department of Defense Handoff Model. And our June 30, 2009 Patient Safety Tip of the Week “iSoBAR: Australian Clinical Handoffs/Handovers” highlighted the iSoBAR format.
The AHRQ Patient Safety Primer Handoffs and Signouts also has links to some good resources on handoffs.
Your nursing staff is probably pretty good at using structured formats for handoffs. Your housestaff is probably also pretty good at using structured handoff tools. You may even have electronic versions of such tools for them. But what about others who do handoffs? Attending physicians in academic settings (other than possibly emergency departments) probably don’t do their own handoffs very often using structured formats. Attendings in community hospitals cross-covering for each other seldom use them. Nursing administrators and hospital administrators on-call almost never use them. And personnel in ancillary departments, like lab and radiology, may not use them either. The question is “Why not?”. We can give you anecdotes about fumbled handoffs in every one of those scenarios that had a real or potential impact on patient care.
We think that videotaping handoffs between a variety of healthcare workers and using those tapes to provide constructive feedback as a way to improve the handoff process also makes a lot of sense. They can provide one of the only ways to determine whether the handoff was truly a two-way communication, i.e. the “receiver” had the opportunity to ask questions and clarify issues. Though that is time consuming, the return on investment is immense when you think about the potential adverse outcomes that might be avoided with better handoffs.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
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 “ ”
April 13, 2010 “Update on Handoffs”
Bhabra G, Mackeith S, Monteiro P, Pothier D. An experimental comparison of handover methods. Ann R Coll Surg Engl 2007; 89: 298–300
Pothier D, Monteiro P, Mooktiar M, Shaw A. Pilot study to show the loss of important data in nursing handover. British Journal of Nursing 2005; 14(20): 1090 - 1093
Royal College of Physicians. Acute Care Toolkit 1. Handover. May 2011.
handover proceedings sheet
Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. American Journal of Emergency Medicine, The Vol. 29, Issue 5, Pages 502-511
Ross CT, Seupaul RA. Minimizing medical error: standardization of patient handoff in the ED. American Journal of Emergency Medicine, The Vol. 29, Issue 5, Pages 567-568
Kahol K, Smith M, Brandenberger J, et al. Impact of Fatigue on Neurophysiologic Measures of Surgical Residents. J Am Coll Surg 2011; 213: 29-36
Cheung DS, Kelly JJ, Beach C, et al for the American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 2010; 55(2): 171-180 February 2010
Joint Commission Center For Transforming Healthcare. Hand-off Communications Project homepage.
Story Boards for the Hand-off Communications Project
Joint Commission Journal on Quality and Patient Safety. Theme Issue on Handoffs. Volume 36, Issue 2. February 2010
Anderson J, Shroff D, Curtis A, Eldridge N, Cannon K, Karnani R, Abrams T, Kaboli P.
The Veterans Affairs Shift Change Physician-to-Physician
Handoff Project. Joint Commission Journal on Quality and Patient Safety 2010;
36(2): 62-71 February 2010
Bernstein JA, Imler DL, Sharek P, Longhurst C. Improved
Physician Work Flow After Integrating Sign-out Notes into the Electronic
Medical Record. Joint Commission Journal on Quality and Patient Safety 2010;
36(2): 72-78 February 2010
Patterson ES, Wears RL. Patient Handoffs: Standardized and Reliable Measurement Tools Remain Elusive. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 52-61 February 2010
Runy LA. Patient Handoffs. Hospitals & Health Networks. May 2008
AHRQ. Patient Safety Primers. Handoffs and Signouts.