AHRQ Patient Safety Network

The Collection > Structured Hand-offs

PATIENT SAFETY PRIMERS
Handoffs and Signouts

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (7)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (172)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (19)

•Medical Complications (3)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (21)

•Psychological and Social Complications (3)

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•Asia (1)

•Australia and New Zealand (10)

Resource Types

•Journal Article (147)

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•Meeting/Conference (1)

•Newspaper/Magazine Article (16)

•Special or Theme Issue (3)

•Tools/Toolkit (5)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (32)

•Active Errors (36)

•Latent Errors (25)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (151)

•Nursing (27)

•Pharmacy (4)

Target Audience

•Health Care Providers (143)

•Health Care Executives and Administrators (143)

•Non-Health Care Professionals (42)

•Patients (5)

Setting of Care

•Hospitals (157)

•Residential Facilities (3)

•Ambulatory Care (11)

•Outpatient Surgery (1)

•Patient Transport (9)

1 - 20 of 186

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STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

STUDY

Impact of resident workload and handoff training on patient outcomes.

Mueller SK, Call SA, McDonald FS, Halvorsen AJ, Schnipper JL, Hicks LS. Am J Med. 2012;125:104-110.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

STUDY

Handing over patient care: is it just the old broken telephone game?

Zendejas B, Ali SM, Huebner M, Farley DR. J Surg Educ. 2011;68:465-471.

COMMENTARY

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.

Bernstein J, MacCourt DC, Jacob DM, Mehta S. Clin Orthop Relat Res. 2010;468:2627-2732.

STUDY

Evaluation of a physician informatics tool to improve patient handoffs.

Flanagan ME, Patterson ES, Frankel RM, Doebbeling BN. J Am Med Inform Assoc. 2009;16:509-515.

STUDY

What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Qual Saf Health Care. 2009;18:248-255.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

STUDY

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2013;53:430-440.

COMMENTARY

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.

Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I. Acad Med. 2012;87:411-418.

STUDY

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2013;39:213-220.

STUDY

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

Coverdill JE, Carbonell AM, Fryer J, et al. Acad Med. 2010;85:S72-S75.

STUDY

Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications.

Philibert I. Qual Saf Health Care. 2009;18:261-266.

STUDY

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer.

Young JQ, Pringle Z, Wachter RM. Jt Comm J Qual Patient Saf. 2011;37:300-308.

COMMENTARY

The top 10 list for a safe and effective sign-out.

Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

STUDY

Physicians-in-training attitudes on patient safety: 2003 to 2008.

Sorokin R, Riggio JM, Moleski S, Sullivan J. J Patient Saf. 2011;7:132-137.

REVIEW

Hospitalist handoffs: a systematic review and task force recommendations.

Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

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