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 (6)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (170)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (18)

•Medical Complications (3)

•Surgical Complications (20)

•Psychological and Social Complications (3)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (10)

Resource Types

•Journal Article (144)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newspaper/Magazine Article (15)

•Special or Theme Issue (3)

•Tools/Toolkit (5)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (31)

•Active Errors (34)

•Latent Errors (24)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (146)

•Nursing (27)

•Pharmacy (4)

Target Audience

•Health Care Providers (140)

•Health Care Executives and Administrators (140)

•Non-Health Care Professionals (42)

•Patients (5)

Setting of Care

•Hospitals (153)

•Residential Facilities (3)

•Ambulatory Care (11)

•Outpatient Surgery (1)

•Patient Transport (9)

1 - 20 of 182

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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

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

The Veterans Affairs shift change physician-to-physician handoff project.

Anderson J, Shroff D, Curtis A, et al. Jt Comm J Qual Patient Saf. 2010;36:62-71.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

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

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.

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.

REVIEW

Improving patient handovers from hospital to primary care: a systematic review.

Hesselink G, Schoonhoven L, Barach P, et al. Ann Intern Med. 2012;157:417-428.

COMMENTARY

Implementing a perioperative handoff tool to improve postprocedural patient transfers.

Petrovic MA, Martinez EA, Aboumatar H. Jt Comm J Qual Patient Saf. 2012;38:135-142.

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.

COMMENTARY

A handoff is not a telegram: an understanding of the patient is co-constructed.

Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC. Crit Care. 2012;16:303.

STUDY

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

Apker J, Mallak LA, Applegate EB 3rd, et al. Ann Emerg Med. 2010;55:161-170.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

MULTI-USE WEBSITE

Hand-off Communications.

Joint Commission Center for Transforming Healthcare.

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.

STUDY

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

Nakayama DK, Lester SS, Rich DR, Weidner BC, Glenn JB, Shaker IJ. J Pediatr Surg. 2012;47:112-118.

COMMENTARY

I-PASS, a mnemonic to standardize verbal handoffs.

Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. Pediatrics. 2012;129:201-204.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.

COMMENTARY

Implementing handoff communication.

Ardoin KB, Broussard L. J Nurses Staff Dev. 2011;27:128-135.

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