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Am J Med. 2015 Sep;128(9):994-1000. doi: 10.1016/j.amjmed.2015.03.023. Epub 2015 Apr 8.

Increased Mortality Rates During Resident Handoff Periods and the Effect of ACGME Duty Hour Regulations.

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Department of Internal Medicine, Bellevue Hospital Center, New York University School of Medicine, New York. Electronic address:
Department of Emergency Medicine, New York University School of Medicine, New York.
Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York.
Division of Pulmonary, Critical Care and Sleep Medicine, Bellevue Hospital Center, New York University School of Medicine, New York.



Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations.


Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes.


Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56).


Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.


Duty hours; Handoff; Handover; Mortality; Resident duty-hour reform; Transitions of care

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