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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 34Handoffs: Implications for Nurses

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Author Information

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1 Mary Ann Friesen, M.S.N., R.N., C.P.H.Q. Program Manager, Center for American Nurses, Silver Spring, MD 20910-3492. E-mail: gro.sesrunnaciremarofretnec@neseirf.yram
2 Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q. Associate Chief Nurse, James A. Haley Veterans’ Hospital, Tampa, FL 33612. E-mail: vog.av@4etihW.nasuS
3 Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. Professor, College of Nursing, University of Central Florida, Orlando, FL 32816-2210. E-mail: ude.fcu.liam@sreybj

Background

The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff.1–3 An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the effects of ineffective handoffs: adverse events and patient safety risks.4–11 The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first”12 (p. 45). This chapter presents an overview of handoffs, a summary of selected literature, gaps in the knowledge, and suggestions for quality improvement initiatives and recommendations for future research.

What Is a Handoff?

First one needs to recognize the term “handoff” and synonymous terms that are used in a wide variety of contexts and clinical settings. There are a number of terms used to describe the handoff process, such as handover,1, 13, 14 sign-out,15, 16 signover,17 cross-coverage,18, 19 and shift report.20–22 For the purpose of this discussion, the term “handoff” will be used and defined as, “The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm”23 (p. 31). The concept of a handoff is complex and “includes communication between the change of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care”1 (p. 1). The handoff is also “a mechanism for transferring information, primary responsibility, and authority from one or a set of caregivers, to oncoming staff”17 (p. 1). So, conceptually, the handoff must provide critical information about the patient, include communication methods between sender and receiver, transfer responsibility for care, and be performed within complex organizational systems and cultures that impact patient safety. The complexity and nuance of the type of information, communication methods, and various caregivers for each of these factors impact the effectiveness and efficiency of the handoff as well as patient safety.

Why Is There a Problem With Handoffs Today?

As health care has evolved and become more specialized, with greater numbers of clinicians involved in patient care, patients are likely to encounter more handoffs than in the simpler and less complex health care delivery system of a few generations ago.11 Ineffective handoffs can contribute to gaps in patient care and breaches (i.e., failures) in patient safety, including medication errors,19, 24 wrong-site surgery,9 and patient deaths.4, 7 Clinical environments are dynamic and complex, presenting many challenges for effective communication among health care providers, patients, and families.25–27 Some nursing units may “transfer or discharge 40 percent to 70 percent of their patients every day”28 (p. 36), thereby illustrating the frequency of handoffs encountered daily and the number of possible breaches at each transition point.

Our expanding knowledge base and technological advances in health care spawn additional categories of health care providers and specialized units designed for specific diseases, procedures, and phases of illness and/or rehabilitation. This dynamic, ever-increasing specialization, while undertaken to improve patient outcomes and enhance health care delivery, can contribute to serious risks in health care delivery and promote fragmentation of care and problems with handoffs.3, 10, 29 It is ironic that as health care has become more sophisticated due to advances in medical technology focused on saving lives and enhancing the quality of life, the risks associated with the handoffs have garnered attention in the popular press30 and reports from health care organizations and providers.3, 4, 6, 10, 31–35 The hazard that “fumbled handoffs”7, 10 pose to patient safety and the delivery of quality health care cannot be ignored. Ineffective handoffs can lead to a host of patient safety problems; research1 and development of strategies to reduce these problems are required.33, 34

What contributes to fumbled handoffs? An examination of how communication breakdown occurs among other disciplines may have implications for nurses. A study of incidents reported by surgeons found communication breakdowns were a contributing factor in 43 percent of incidents, and two-thirds of these communication issues were related to handoff issues.36 The use of sign-out sheets for communication between physicians is a common practice, yet one study found errors in 67 percent of the sheets.15 The errors included missing allergy and weight, and incorrect medication information.15 In another study, focused on near misses and adverse events involving novice nurses, the nurses identified handoffs as a concern, particularly related to incomplete or missing information.37

Acute care hospitals have become organizationally complex; this contributes to difficulty communicating with the appropriate health care provider. Due to the proliferation of specialties and clinicians providing care to a single patient, nurses and doctors have reported difficulty in even contacting the correct health care provider.38 One study found that only 23 percent of physicians could correctly identify the primary nurse responsible for their patient, and only 42 percent of nurses could identify the physician responsible for the patient in their care.39 This study highlights the potential gaps in communication among health care providers transferring information about care and treatment.

A handoff is largely dependent on the interpersonal communication skills of the caregiver33 as well as the knowledge and experience level of the caregiver. There is reported variability in quality,40 lack of structure in how handoffs usually occur,33 and variances in shift handoffs.22, 41–43 Concern has been raised that the transition of care between providers during handoffs will continue to be problematic as research indicates that “only 8 percent of medical schools teach how to hand off patients in formal didactic session”3 (p. 1097), creating a large educational gap in new professionals and persistence of traditional models. Physicians and nurses communicate differently. Nurses are focused on the “big picture” with “broad and narrative”44 (p. i86) descriptions of the situation, whereas physicians are focused on bullets of critical information.44 A technique that seeks to bridge the gap between the different communication styles of nurses and physician is the situation, background, assessment, recommendation (SBAR) briefing model44 that is being used successfully to enhance handoff communication.45

The issue of handoffs has become so prominent that the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCAHO) introduced a national patient safety goal on handoffs that became effective in January 2006.45 The national safety goals, developed by the Joint Commission with input from the Sentinel Event Advisory Group, identify new actions with the potential to protect patient safety.46 The patient safety goal requires health care organizations to “implement a standardized approach to “handoff” communications, including an opportunity to ask and respond to questions.”47 While the goal is simply stated, it is challenging to develop and implement effective strategies for handoffs across various health care settings, given the complexity of health care delivery. The Joint Commission’s guidelines for implementation of the safety goal are presented in Table 1,48 and suggested strategies for effective handoffs are listed in Table 2.

Table 1

Table 1

Joint Commission 2008 Hospital Patient Safety Goals Implementation Expectations for Handoffs

Table 2

Table 2

Strategies to Improve Handoff Communication

Following are examples of each of these handoff expectations:

  1. Nurse Brown on unit A is receiving report from Nurse Green who is transferring the patient from unit B to unit A. The patient medication administration record (MAR) does not indicate the patient has received any pain medication in the past shift. When Nurse Brown asks about this, Nurse Green realizes she gave morphine sulfate but did not document it on the MAR. Due to Nurse Brown’s question, Nurse Green realizes the omission and communicates the information and documents it in the medical record, preventing an accidental overdose of a medication.
  2. A patient who had undergone a surgical procedure has not been out of bed since being transferred to the nursing unit. The offgoing nurse alerts the oncoming nurses that the patient will need help getting out of bed, possibly preventing a patient fall.
  3. Handoffs require a process for verification of the received information, including read back, as appropriate. For example, the receiver of the telephone message regarding a laboratory value is asked to write it down and read the message back, including the name of the patient, the test, and the test result/interpretation.49, 50 Information to be recorded should also include the name and credentials of sender and receiver and the date and time.50
    Laboratory Technician: I am calling with the lab results on Mr. Green.
    Nurse: Let me get a notepad. You are calling the lab results for Mrs. Marie White?
    Laboratory Technician: No, I am calling results for Mr. Tom Green ID #12345678. Mr. Green’s potassium level is 5.1, which was drawn at 0700 today.
    Nurse: You reported that Mr. Tom Green’s potassium level is 5.1. This is Nancy Jones, RN.
    Laboratory Technician: Thank you, Nancy. That is correct; Mr. Tom Green’s potassium level is 5.1 This is Bill Smith, lab tech.
  4. The receiver of the handoff information has an opportunity to review relevant patient/client/resident historical data, which may include previous care, treatment, and services. A patient has been transferred, and the nurse notes several omissions from previous medication orders, including insulin. The nurse notifies the physician and obtains correct and complete medication orders, thereby avoiding a potentially serious medication error.
  5. A nursing unit schedules staffing coverage to accommodate the shift change and minimize the occurrence of interruptions during change-of-shift report. Ancillary staff does not leave the nursing unit until report is completed to assure phones are answered and timely responses to call lights are made so nurses can provide report effectively and efficiently.

It is important to understand the context in which care is provided and be cognizant of the impact of the environmental processes on health care providers. The physical work environment may not be conducive to effective handoffs as it may be noisy58, 59 and prone to interruptions, (i.e., pagers, phone calls),60–63 and the handoff may be conducted under physical and emotional pressures.11 A study examining communication patterns among physicians and nurses found thirty one percent of communication exchanges involved interruption, translating into roughly 11 interruptions an hour for physicians and nurses.60 Spencer and colleagues62 found 15 interruptions per hour. Barriers to transmission of accurate information in a patient transfer include incomplete medical record, lack of complete information provided by nurses, and the omission of essential information.64 Handoffs are compromised if critical pieces of information are omitted because of difficulties with data access4, 29 or if documentation is illegible31, 33 or not transferred.55 Despite efforts to promote the use of electronic patient records, according to a 2002 survey, less than 10 percent of hospitals have complete access to electronic systems such as computerized physician order entry (CPOE).65

The ever-increasing abundance of data requires that health care providers synthesize and make decisions using large amounts of complex information. Unfortunately, data quickly degrades; for example, critically ill patients have many clinical parameters that are being monitored frequently.66 Decisions need to be based on trends in the data and current information, which is essential to making informed decisions.66 Tremendous amounts of information are constantly being generated, such as monitored clinical parameters, diagnostic tests, and multidisciplinary assessments. When this large amount of information is combined with the numerous individuals—clinical and nonclinical—who come in contact with a patient during a treatment episode and data transmission, not all members of the health care team may be aware of all the information pertinent to each patient.66

In an effort to compress information and make it manageable among health care providers, handoffs may result in a “progressive loss of information known as funneling, as certain information is missed, forgotten or otherwise not conveyed” 66 (p. 211). The omission of information or lack of easy accessibility to vital information by health care providers can have devastating consequences.4, 11 Such gaps in health care communication can cause discontinuity in the provision of safe care67 and impede the therapeutic trajectory for a patient. These gaps present major patient safety threats and can impact the quality of care delivered.

Where Do Handoffs Occur?

Handoffs occur across the entire health care continuum in all types of settings. There are different types of handoffs from one health care provider to another, such as in the transfer of a patient from one location to another within the hospital64 or the transition of information and responsibility during the handoff between shifts on the same unit.1, 41, 43 Interdisciplinary handoffs occur between nurses and physicians, and nurses and diagnostic personnel, while intradisciplinary handoffs occur between physicians3, 15, 31 or between nurses.13, 14, 41, 42,43 Interfacility handoffs occur between hospitals and among multiple organizations,68 including home health agencies,69, 70 hospices,71 and extended-care facilities.72, 73

Handoffs may involve use of specialized technology (e.g., audio recorders, pagers, hand-held devices, and computerized records),2 fax,73, 74 written documents,54 and oral communication.41, 75, 77 Each type and location of handoff presents similar as well as unique challenges. Given the variety of handoffs, the following discussion will focus on:

  • Shift-to-shift handoff
  • Nursing unit-to-nursing unit handoff
  • Nursing unit to diagnostic area.
  • Special settings (operating room, emergency department).
  • Discharge and interfacility transfer handoff
  • Handoffs and medications
  • Physician-to-physician handoffs

Shift-to-Shift Handoff

There are paradoxes in communication and handoffs, especially at shift changes.20 Many human factors play a role. Human factors (ergonomics) focus on behavior and interaction between human beings and their environment. Human factors engineering focuses on “how humans interact with the world around them and the application of that knowledge to the design of systems that are safe, efficient, and comfortable”76 (p. 3). The handoff poses numerous human factors engineering implications. From the perspective of patient safety, the primary purpose of the shift report or shift handoff is to convey essential patient care information,14, 43, 55, 78, 79 promote continuity of care13, 41, 77, 78, 80 to meet therapeutic goals, and assure the safe transfer of care of the patient to a qualified and competent nurse. However, other reported purposes of shift report include education,41, 78, 81 debriefing,14, 41 socialization,78, 82 planning and organization,78 enhancement of teamwork,81 and supportive functions.83

The intershift handoff is influenced by various factors, including the organizational culture. An organization that promotes open communication and allows all levels of personnel to ask questions and express concerns in a nonhierarchical fashion is congruent with an environment that promotes a culture of safety.58 Interestingly, one study reported novice nurses seeking information approached those seen as “less authoritarian.”84 The importance of facilitating communication is critical in promoting patient safety. The shift-to-shift handoff is a multifaceted activity.78, 85, 86 A poor shift report may contribute to an adverse outcome for a patient.55

Handoff intricacies

A phenomenon well known to nurses is the use of nurse-developed notations, “cheat sheets” or “scraps” of information, while receiving or giving intershift reports. A study of such note taking found scraps are used for a variety of purposes, including creating to-do lists and recording specific information and perceptions about the patient and family.87 This approach presents some challenges, as no one else has easy access to the information; therefore, continuity of care may be compromised during a meal break, for example, or if the scrap or cheat sheet is misplaced.

Method of shift-to-shift handoff

Handoffs are given using various methods:13, 41, 88, 89 verbally,75, 77 with handwritten notes,80, 87 at the bedside,41, 52, 56, 57, 90, 92 by telephone,91 by audiotape,41, 53 nonverbally,54 using electronic reports,92 computers printouts,14 and memory.14 The strength of the bedside report method is its effort to focus on and include the patient in the report. There have been concerns regarding patient confidentiality,41, 52, 56, 90 which could be compromised if not carefully addressed. A qualitative study focused on describing the perceptions of patients who were present during a bedside report found some patients are in favor of bedside handoff, while others are not.52 Patients also expressed concern regarding the jargon used by nurses.52 One patient noted that including the patient in the handoff added another level of safety as erroneous data could be addressed and corrected.52 Case studies indicate the bedside handoff may be implemented for a number of reasons, including addressing specific issues and improving care delivery.57, 92 A summary of the strengths and weaknesses of verbal, bedside, written, and taped shift-to-shift reports is included in Table 3.

Table 3

Table 3

Nurse-to-Nurse Change-of-Shift Handoff Report

The challenge during handoffs across settings and times is to identify methods and implement strategies that protect against information decay and funneling,66 contributing to the loss of important clinical information. It is a challenge to develop a handoff process that is efficient and comprehensive, as case studies illustrate.57, 88, 92, 93 Observation of shift handoffs reveals that 84.6 percent of information presented in handoffs could be documented in the medical record.42 A concern that emerged in this study was some handoff reports actually “promote confusion,” and therefore the authors advocated improving the handoff process.42

Another concern with handoffs is the degree to which the report is actually congruent with the patient’s condition. One study found 70 percent congruence between the shift report and the patient’s actual condition, with an omission rate of 12 percent.22 A synthesized case example of a psychiatric patient presents the adverse consequences for the patient if essential information is not communicated.94 The importance of communicating objective descriptions of the patient condition is highlighted.

A study focusing on assessing the effects of manipulating information in a shift handoff on the receiving nurse’s care planning found in the different types of taped reports that the information recalled ranged from 20 percent to 34 percent.95 Another study, by Pothier and colleagues,55 examined different methods for transferring information during 5 consecutive simulated handoffs of 12 fictional patients. Three methods of handoffs were analyzed; the method demonstrating the greatest amount of information retention involved utilization of a preprinted sheet containing patient information with verbal report, followed by note taking and verbal report method, and lastly, only verbal report. The retained total data points for each style of handoff varied considerably during the five handoffs. Over 96 percent to 100 percent of information was retained using the preprinted sheet containing patient information and verbal report. Only 31 percent to 58 percent of the data were retained using the note taking style and verbal report.55 The verbal-only style demonstrated the greatest amount of information loss, with retention ranging from 0 percent to 26 percent.55 None of the data was retained using the verbal-only method for two handoff cycles. The insertion of incorrect information was observed in the verbal-only method. The generation of incorrect data did not occur at all during the handoff with the written or preprinted form style of report. This study55 supports the use of a consistent preprinted form with relevant patient information during shift report, with less reliance on verbal-only reports, in order to optimize communication.

Nursing Unit-to-Nursing Unit Handoff

Patients may be transferred frequently during their hospital stays.28 Yet, the patient transfer is fraught with potential problems and can have an adverse impact on patients.96, 97 Issues have been identified in the transfer handoff process, including incomplete medical records and omission of essential information during the handoff report.64 A number of factors that contribute to inefficiency during patient transfers from one nursing unit to another have been identified,97 including delay or wasted time caused by communication breakdowns, waiting for responses from other nurses or physicians or a response from patient placement management or bed control.97 Bed control involves personnel who manage the bed assignments of new and transferring patients. Decreasing the number of transfers is a possible strategy to decrease risks associated with handoffs.58

Nursing Unit to Diagnostic Area

Patients are frequently sent from a nursing unit to diagnostic areas during the normal course of a hospitalization. Transfers have been cited as a contributor to medication errors between nursing units and diagnostic areas (e.g., radiology, cardiac catheterization, nuclear medicine).19 It is important when patients change nursing units, particularly to a different level of care, or go to a procedure in another department that there is clear, consistent communication and that the receiving area staff have the information they need to safely care for the patient.34 Complexity of the patient’s condition may require that the nurse caring for the patient actually accompanies the patient to the new setting.

Special Settings

Operating room and postanesthesia

Several special handoff situations occur in certain hospital settings. The operating room (OR) is considered “one of the most complex work environments in health care”98 (p. 159), with a reported mean of 4.8 handoffs per case. Nursing staff average 2.8 handoffs per case, with a range of one to seven handoffs.98

There have been at least 615 wrong-site surgeries reported to the Joint Commission between 1995 and 2007.99 To help prevent wrong-site surgery, the Joint Commission developed the Universal Protocol for Preventing Wrong Site Surgery, Wrong Procedure, Wrong Person SurgeryTM.100, 101 It is based on the consensus of experts and endorsed by more than 50 professional organizations.100 Effective interdisciplinary communication is critical. For example, a health care organization using a perioperative briefing process reported that no wrong-site surgeries have occurred since the adoption of the interdisciplinary briefings.44

Dierks suggests five categories for handoffs in the OR: (1) baseline metrics/benchmarks, (2) most recent phase of care, (3) current status, (4) expectations for the next phase of care, and (5) other issues such as “who is to be contacted for specific issues”102 (p. 10). The use of a team checklist in the OR was pilot tested in another study and found to show “promise as a method for improving the quality and safety of patient care in the OR”103 (p. 345).

A study focused on OR communication processes identified a number of patterns and found the most common reason for communication in 2,074 episodes was coordination of equipment, followed by “preparedness” for surgery.104 The authors recommend increasing the use of automated processes to enhance process flow, especially related to “equipment management,” thereby helping with transmission of information in a more efficient manner.104

Communication in handoffs is critical in all phases of care. However, a survey of 276 handoffs conducted in a postanesthesia care unit (PACU) revealed 20 percent of postoperative instructions were either not documented or written illegibly.105 The nurses rated the handoffs from anesthesia staff as “good” in 48 percent of cases, “satisfactory” in 28 percent, and “bad” in 24 percent.105 A number of suggestions for improving the quality of the postanesthesia care unit handoff protocol were presented including the need to communicate information verbally to the nurse.105

Emergency department

A study of five emergency departments (EDs) revealed that there were differences in the characteristics of handoffs among the EDs studied, but “nearly universal” attributes of handoffs were also noted.106 The researchers developed a conceptual framework for addressing handoffs in the emergency setting. The handoffs were not one way communication processes as both the offgoing and oncoming providers were engaged in interactive handoffs. 106 According to Behara and colleagues,106 8 of 21 handoff strategies used in other industries2 were observed “consistently” in the ED setting, while four were used less often and nine were not or rarely used. The handoff in the ED setting is viewed as a “rich source for adverse events”17 (p. 1). There are inherent risks in handoffs, but it was also noted that the handoff can provide the opportunity for two health care providers to assess the same situation and identify a “previously unrecognized problem”17 (p. 2).

Studies focused on emergency nursing handoffs highlight unique aspects of this process.107, 108 Currie reported in a survey of 28 ED nurses that the top three concerns nurses had with handoffs were missing information, distractions, and lack of confidentiality.108 Recommendations included the development of guidelines to improve the handoff process in the ED.

Discharge and Interfacility Transfer Handoff

Handoffs from one facility to another occur frequently between many different settings.68–70, 71, 72, 73, 109–111 Handoffs take place between hospitals when patients require a different level of care. The usual interfacility handoffs are between hospitals and long-term care facilities, rehabilitation centers, home health agencies, and hospice organizations. The factor that tends to make these handoffs challenging is gaps and barriers to communication among these agencies.68, 111, 112 Handoffs between facilities are also impacted by the cultural differences between the types of facility.73 Agencies are often geographically separate, requiring physical relocation of the patient, belongings, and paper records. Once the transfer has taken place, seeking additional information becomes a challenge.73

The continuity of patient care requires communication among various health care organizations.68, 71, 73, 110, 113–115 One problem noted is nurses in different settings have different perceptions about what is important to be conveyed, such as different perceptions between the hospital and home health care.70, 116 Another area of concern noted in transfers from hospitals to other health care organizations is incomplete documentation. More information was transmitted when a standard form to communicate information was utilized between a hospital and home health agency (HHA).69 The usage of referral forms varies among health care institutions.109 Rates of transmission of information differ from hospitals to HHAs69, 109, 113 and to extended-care facilities.72 It was found that HHAs affiliated with hospitals received more referral data than free-standing HHAs.113

Discharge planning forms address “the anticipation of a certain type of gap and also of an effort to create a bridge to permit care to flow smoothly over the gap”67 (p. 793). One example of the development of such a form using “a consensus process” resulted in the implementation of a Patient Transition Information Checklist to help improve communication between hospitals and nursing homes.114 Another type of form for communication of patient information among health care organizations was developed in Germany; however, followup revealed use of the form was not as widespread as anticipated because process barriers emerged, precluding users from easily completing and transmitting the forms.111 Development of any type of “patient accompanying form”111 requires numerous considerations and a balance between being comprehensive and not being cumbersome to use.111 There also needs to be adequate resources to allow health care providers to retrieve necessary data and transmit patient information between agencies.111

Inadequate discharge planning has been implicated in adverse outcomes of patients.117, 118, 119 A study of 400 patients found 76 patients incurred an adverse outcome after discharge from the hospital. The researchers reported “ineffective communication contributed to many of the preventable and ameliorable adverse events”119 (p. 166). The most frequent type of adverse event was related to medications. The implications of this study indicate the need to enhance communication in the handoff between the hospital and posthospital care. Suggested potential strategies to improve the handoff include discharge planning and education of patients related to medications prior to discharge.119

A number of contributors to a failed handoff in the discharge planning process have been identified, including, lack of knowledge about the discharge process,117 lack of time,117 lack of effective communication,119, 120 patient and family issues,117, 120 system issues,120 and staffing issues.117, 120 Communication issues have emerged as a potential contributor to readmissions.121 An ineffective nursing handoff has been identified as a contributor to miscommunication within the discharge process.122 The improvement of discharge planning requires that emphasis be placed on collaboration and interdisciplinary communication.112 Well-orchestrated discharge planning is recommended to help improve patient safety123 by controlling the risk of gaps occurring in the discharge process and its inherent handoffs.

Handoffs and Medications

Medication errors are considered preventable events.124 Handoff issues (e.g., transfer, shift change, cross-coverage) have been identified by the United States Pharmacopeia (USP) through its MEDMARX® reporting program as a contributing factor to medication errors within health care organizations.19, 24

Incomplete transfer of medication information is recognized as a possible contributor to patient safety problems as patients are discharged from the hospital.119, 125 Reasons for medication handoff failures include incomplete patient education and the “inability of ambulatory care providers (including nursing homes) to receive discharge medication information”126 (p. 93). Medication changes during the transition (handoff) from hospital to skilled nursing facilities were identified as a cause of adverse drug events in a New York study.127 One study reported patients who received medication information and counseling demonstrated more compliance with their medication regimen than patients who did not receive such information.128

There are multiple case examples of medication errors related to handoffs across the continuum of care.129, 130 In fact, USP has reported that 66 percent of medication reconciliation errors occur during the transfer or transition of a patient to another care level.130 A number of recommendations have been developed to improve the medication reconciliation process and reduce risks for patients.130, 131 In addition, medication reconciliation is a Joint Commission patient safety goal,47 with specific requirements for the process.47, 132

Physician-to-Physician Handoffs

Studies conducted to better understand physician-to-physician handoffs31, 33 may have implications for nurses. Poor handoffs included omissions of essential information such as medications, code status, and anticipated problems.31 Other issues contributing to failed communication processes included lack of face-to-face interaction and illegible documentation.31 The weaknesses identified in another handoff study included incomplete and or illegible information, difficulty accessing clinical information quickly, communication failures, and difficulty contacting other doctors.33 Strategies to address handoff problems include providing legible, accurate, relevant, comprehensive information and the use of a face-to-face report.31 Suggestions for improvement include development of a process to enhance transmission of information, for example, the adoption of templates; use of technology; use of communication processes such as SBAR, education, and evaluation of handoffs;31 and a standardized handoff process.33

Evidence-Based Practice Implications—Handoffs for Today’s Health Care Environment

The Australian Council for Safety and Quality in Health Care evaluated 777 papers for possible inclusion in a literature review on handoffs.1 A total of 27 papers met the inclusion criteria, but it was reported that “no best practice” (p. 2) existed related to systems emerged in the search—although a number of recommendations were provided for systems, organizational, and individual factors.1 Handoffs are an extremely complex phenomenon to study as they occur in a variety of settings; stages along the continuum of care; and among various personnel with different skill sets, priorities, and educational levels.

Contributors to handoff problems included failed communication,4, 5, 6, 7, 10, 31 omissions,31, 64, 108 distractions,108 lack of or illegible documentation,31, 33, 73 lack of utilization of transfer forms,69 incomplete medical records,64 lack of medication reconciliation,129, 130 and lack of easy accessibility to information.6, 33, 73 A variety of environmental issues emerged—including designs28, 58—that served to increase, rather than decrease, the number of handoffs. Interfacility handoffs posed a number of challenges, including cultural differences73 and lack of integrated systems, thereby increasing the likelihood of transmission difficulties between organizations. Organizational and system failures or lack of systems to support the handoff process emerged as contributors to adverse events.4, 6, 7, 10 A lack of knowledge was found regarding effective handoff processes,117 and education on effective handoff strategies was also lacking.3, 117 Handoff processes need to include consideration of the person involved in the handoff and their level of education, expertise, and comprehension (e.g., the novice nurse’s informational needs may be different from the expert nurse).41 Novices also differ from expert nurses in their use of information.84

There must be an organizational commitment to the development and implementation of systems that support effective handoffs as well as a just culture.133, 134 This includes cultures of safety and learning.134 A safety culture supports identifications of problems and errors to be addressed to prevent the recurrence.134–136 A culture of learning promotes learning from the experiences of the past to prevent a recurrence of tragic fumbled handoffs. Environments and processes need to be designed to promote desired outcomes76 and enhance patient safety.137

Electronic Support of Handoffs

A number of reports and studies have called for systems that allow ease of access to accurate information to improve handoffs.6, 10, 15, 29, 89, 138 Electronic technology requires that design issues be considered and adequate resources be allocated for successful implementation and acceptance.139 Research of computerized support for physician handoffs suggests this is a strategy that merits further consideration and evaluation.16 A study at two hospitals reported the implementation of a computerized system for resident handoff enhanced delivery of care and decreased the number of patients missed on rounds.138 There have been limited studies on computerized clinical documentation systems (CDS) in the nursing shift handoff. One study reported nurses perceived shift-to-shift handoffs more positively after the implementation of the CDS.140 Access to a physician computerized sign-out was rated positively by nurses and was reported to improve communication.141

Decrease Transfers of Patients

Decreasing the number of patient transfers may reduce the risks that occur during handoffs.58 It has been suggested that “many patient transfers could be prevented by altering facility designs and nursing care models found in acute care hospitals”97 (p. 163), thereby decreasing the need for handoffs. The implementation of “acuity-adaptable rooms” demonstrated a 90-percent decrease in patient transports; the same study also reported a decrease in medication errors of 70 percent.28 More research of this strategy is recommended.58

Effective Handoff Process

A recurrent theme observed in the handoff literature is the need to convey essential information to the oncoming shift or provider. A standardized process to guide the transfer of critical information has been recommended.33, 34, 45, 48, 108 The use of protocols that include the use of phonetic and numeric clarifications are important in helping convey information accurately.11, 136 The Sentara health care organization adopted behavior-based expectations to improve the handoff process and used tools including the five Ps (patient/project, plan, purpose, problems, and precautions).136 It reported a 21-percent increase in effective handoffs.142 A medical center using SBAR in the handoff process reported less missing information in handoffs after implementation of SBAR.45 The use of protocols such as safe practice recommendations related to reconciling medications131, 132 and communicating critical test results49, 50 should be used in designing strategies for more effective handoffs. Some hospitals have reported developing strategies to improve the communication between the hospital and other providers.44, 71, 73, 74, 114 A summary of problems and barriers with handoffs observed in this review of literature are presented in Tables 4, 5, and 6. Strategies that have been reported in the literature are also included in the tables; however, more research is needed to identify evidence-based guidelines. The Evidence Table at the end of this chapter presents a summary of selected sources addressing handoffs.

Table 4

Table 4

Factors, Problems, and Strategies Cited in the Literature

Table 5

Table 5

Issues, Problems, and Strategies Cited in the Literature

Table 6

Table 6

Issues, Problems, and Strategies Cited in the Literature

Evidence Table

Evidence Table

Selected Sources on Handoffs—Nursing Handoffs, Quality Improvement Activities, Interdisciplinary Handoffs

Human Factors

The study of human factors engineering is currently being used to improve patient safety,76 and there are an increasing number of strategies and tools that can be used to design systems in a manner to decrease adverse outcomes. Designs to promote patient safety should include integration with “forcing” functions to prevent errors. However, there needs to be testing of proposed solutions to assure validity of these tools in the health care environment.76 Lessons learned from other industries are fostering the adoption of human factors principles and increasingly being used in health care.44, 137, 143–146

Studies of handoffs in other industries have been analyzed for possible implications for health care. Patterson and colleagues2 analyzed data from four studies147–150 and described 21 handoff strategies. According to their findings, strategies that could be applied to shift handoff included interactive questioning, face-to-face handoff, forcing functions such as passing a pager to initiate handoff to the oncoming nurse to indicate an unambiguous transfer of responsibility, flagging critical information, and reduction of interruptions.2 The researchers note a question remains “if the strategies can be generalized to health care”2 (p. 132), and call for additional research in this area.

Research Implications

Following are suggested questions for future research:

  • What are the best systems designs to reduce unnecessary handoffs? How can they best be implemented?
  • What are best strategies for handoffs in various settings (i.e., nurse to nurse, unit to unit, agency to agency, physician to nurse)?
  • What are the most effective strategies, instruments, and tools to employ to assure maximum transfer of and receipt of accurate, relevant, up-to-date information?
  • How can electronic technology best be deployed to support and enhance effective handoffs, decrease errors, and improve patient safety and patient outcomes?
  • What are the best techniques for assuring critical information is forwarded and not omitted or overlooked when received?
  • How can handoff contributors to medication errors be addressed and decreased?
  • What are the critical data elements that should be transferred by type of service, specialty, profession, and setting?

Basic to the provision of quality health care is the ability to communicate with one another and safely handoff patient care in a seamless manner so every patient can benefit from each phase of care through a well-executed handoff. This is a process that is ubiquitous but also a high-risk endeavor in many settings. More research is needed in this critical patient safety arena to promote interdisciplinary approaches to patient safety throughout the continuum of care.

Search Strategy

To retrieve pertinent literature on the topic of handoffs, the following databases were reviewed: Academic Search Premier, CINAHL, Pre-CINAHL, EMBASE, Ovid’s Medline, PubMed, and PsychInfo. The databases were searched for variants of the words “handover” and “handoff,” “shift report,” and “changeover.” Additionally, the databases were searched for groups of subject terms representing the concepts of patient transfer, communication, and continuity of care. The use and combination of subject headings varied depending on the characteristics of each database. Searches for the concept of patient transfer used the following subject headings: transfer, discharge; transfer, intrahospital; patient discharge; transportation of patients; and patient transfer. The concept of communication was represented by terms such as “communication barriers,” “communication,” “communication skills,” “communication theory,” and “interpersonal communication.” Subject headings focusing on the concept of overall health care delivery or quality included quality of care, health care delivery, continuity of patient care, patient safety, and medical care.

Acknowledgments

Acknowledgment

The authors wish to acknowledge Stephanie Narva Dennis, M.L.S., for support and assistance in conducting the literature search.

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