Handoffs and Signouts
Background
Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, so patients will inevitably be cared for by many different providers during hospitalization. Nurses change shift every 8 to 12 hours, and, particularly at teaching institutions, multiple physicians may be responsible for a patient's care at different times of the day. This discontinuity creates opportunities for error when clinical information is not accurately transferred between providers. As one author put it, "for anyone who has watched children playing 'Telephone'…the inherent potential for error in signouts is obvious." The problems posed by handoffs of care have gained more attention since the 2003 implementation of regulationslimiting housestaff duty hours, which has led to greater discontinuity among resident physicians.
Source: Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15:30-37. [go to PubMed]
The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient. (This Primer will discuss handoffs and signouts in the context of transfers of care during hospitalization. For information about safety issues at the time of hospital discharge, please see the related Patient Safety Primer Adverse Events after Hospital Discharge.)
Handoffs and signouts have been linked to adverse clinical events in settings ranging from the emergency department to the intensive care unit. Onestudy found that being cared for by a covering resident was a risk factor for preventable adverse events; more recently, communication failures between providers have been found to be a leading cause of preventable error in studies of closed malpractice claims affecting emergency physicians and trainees. The seemingly straightforward act of communicating an accurate medication list is a well-recognized source of error. To avert this problem, hospitals are required to "reconcile" medications across the continuum of care. (For more information, see the related Primer "Medication Reconciliation.")
Implementing Effective Handoff and Signout Protocols
Current signout mechanisms are generally ad-hoc, varying from hospital to hospital and unit to unit. Guidelines for safe handoffs focus on standardizing the signout mechanism. The components of a safe and effective signout can be summarized using the acronym ANTICipate:
Current Context
The Joint Commission requires all health care providers to "implement a standardized approach to handoff communications including an opportunity to ask and respond to questions" (2006 National Patient Safety Goal 2E). The Joint Commission National Patient Safety Goal also contains specific guidelines for the handoff process, many drawn from other high-risk industries:
Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, so patients will inevitably be cared for by many different providers during hospitalization. Nurses change shift every 8 to 12 hours, and, particularly at teaching institutions, multiple physicians may be responsible for a patient's care at different times of the day. This discontinuity creates opportunities for error when clinical information is not accurately transferred between providers. As one author put it, "for anyone who has watched children playing 'Telephone'…the inherent potential for error in signouts is obvious." The problems posed by handoffs of care have gained more attention since the 2003 implementation of regulationslimiting housestaff duty hours, which has led to greater discontinuity among resident physicians.
Source: Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15:30-37. [go to PubMed]
The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient. (This Primer will discuss handoffs and signouts in the context of transfers of care during hospitalization. For information about safety issues at the time of hospital discharge, please see the related Patient Safety Primer Adverse Events after Hospital Discharge.)
Handoffs and signouts have been linked to adverse clinical events in settings ranging from the emergency department to the intensive care unit. Onestudy found that being cared for by a covering resident was a risk factor for preventable adverse events; more recently, communication failures between providers have been found to be a leading cause of preventable error in studies of closed malpractice claims affecting emergency physicians and trainees. The seemingly straightforward act of communicating an accurate medication list is a well-recognized source of error. To avert this problem, hospitals are required to "reconcile" medications across the continuum of care. (For more information, see the related Primer "Medication Reconciliation.")
Implementing Effective Handoff and Signout Protocols
Current signout mechanisms are generally ad-hoc, varying from hospital to hospital and unit to unit. Guidelines for safe handoffs focus on standardizing the signout mechanism. The components of a safe and effective signout can be summarized using the acronym ANTICipate:
- Administrative data (eg, patient's name, medical record number, and location) must be accurate.
- New clinical information must be updated.
- Tasks to be performed by the covering provider must be clearly explained.
- Illness severity must be communicated.
- Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in managing the patient overnight.
Current Context
The Joint Commission requires all health care providers to "implement a standardized approach to handoff communications including an opportunity to ask and respond to questions" (2006 National Patient Safety Goal 2E). The Joint Commission National Patient Safety Goal also contains specific guidelines for the handoff process, many drawn from other high-risk industries:
- interactive communications
- up-to-date and accurate information
- limited interruptions
- a process for verification
- an opportunity to review any relevant historical data
What's New in Handoffs and Signouts on AHRQ PSNet
STUDY
Development and validation of a taxonomy of adverse handover events in hospital settings.
Andersen HB, Siemsen IMD, Petersen LF, Nielsen J, Østergaard D. Cogn Technol Work. 2015;17:79-87.
STUDY
An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care.
Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. Anesth Analg. 2015;120:96-104.
STUDY
Associations between perceived crisis mode work climate and poor information exchange within hospitals.
Patterson ME, Bogart MS, Starr KR. J Hosp Med. 2014 Dec 10; [Epub ahead of print].
STUDY
A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.
O'Hara R, Johnson M, Siriwardena AN, et al. J Health Serv Res Policy. 2015;20(suppl 1):45-53.
STUDY
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
STUDY
Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study.
Hudson CCC, McDonald B, Hudson JKC, Tran D, Boodhwani M. J Cardiothorac Vasc Anesth. 2014 Nov 24; [Epub ahead of print].
STUDY
Managing competing organizational priorities in clinical handover across organizational boundaries.
Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Pol. 2015;20(suppl 1):s17-s25.
Development and validation of a taxonomy of adverse handover events in hospital settings.
Andersen HB, Siemsen IMD, Petersen LF, Nielsen J, Østergaard D. Cogn Technol Work. 2015;17:79-87.
An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care.
Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. Anesth Analg. 2015;120:96-104.
Associations between perceived crisis mode work climate and poor information exchange within hospitals.
Patterson ME, Bogart MS, Starr KR. J Hosp Med. 2014 Dec 10; [Epub ahead of print].
A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.
O'Hara R, Johnson M, Siriwardena AN, et al. J Health Serv Res Policy. 2015;20(suppl 1):45-53.
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study.
Hudson CCC, McDonald B, Hudson JKC, Tran D, Boodhwani M. J Cardiothorac Vasc Anesth. 2014 Nov 24; [Epub ahead of print].
Managing competing organizational priorities in clinical handover across organizational boundaries.
Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Pol. 2015;20(suppl 1):s17-s25.
What Have We Learned About Safe Inpatient Handovers?.
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. March 2011
Tacit Handover, Overt Mishap.
Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD. AHRQ WebM&M [serial online]. June 2010
All in the History.
Christopher Fee, MD. AHRQ WebM&M [serial online]. February/March 2009
Triple Handoff.
Arpana R. Vidyarthi, MD. AHRQ WebM&M [serial online]. September 2006
Fumbled Handoff.
Arpana Vidyarthi, MD. AHRQ WebM&M [serial online]. March 2004
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. March 2011
Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD. AHRQ WebM&M [serial online]. June 2010
Christopher Fee, MD. AHRQ WebM&M [serial online]. February/March 2009
Arpana R. Vidyarthi, MD. AHRQ WebM&M [serial online]. September 2006
Arpana Vidyarthi, MD. AHRQ WebM&M [serial online]. March 2004
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2013;8:456-463.
Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.
Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-598.
A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. J Am Coll Surg. 2005;200:538-545.
Handoff strategies in settings with high consequences for failure: lessons for health care operations.Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Int J Qual Health Care. 2004;16:125-132.
Improving Hand-Off Communication.Oakbrook Terrace, IL: Joint Commission Resources; 2007. ISBN: 9781599400907.
Wachter RM, Shojania KG. In: Wachter RM, Shojania KG. Internal Bleeding. New York, NY: Rugged Land; 2004:159-180.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.
Association of Perioperative Registered Nurses.
Oakbrook Terrace, IL: The Joint Commission; 2015.
Accreditation Council for Graduate Medical Education.
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