AHRQ Patient Safety Network

The Collection > Structured Hand-offs

PATIENT SAFETY PRIMERS
Handoffs and Signouts

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (6)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (171)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (16)

•Medical Complications (2)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (18)

•Psychological and Social Complications (3)

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•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 (2)

•Tools/Toolkit (5)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (31)

•Active Errors (33)

•Latent Errors (24)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (144)

•Nursing (26)

•Pharmacy (3)

Target Audience

•Health Care Providers (138)

•Health Care Executives and Administrators (139)

•Non-Health Care Professionals (42)

•Patients (5)

Setting of Care

•Hospitals (152)

•Residential Facilities (3)

•Ambulatory Care (10)

•Outpatient Surgery (1)

•Patient Transport (9)

1 - 20 of 180

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COMMENTARY

Ticket to ride: reducing handoff risk during hospital patient transport.

Pesanka DA, Greenhouse PK, Rack LL, et al. J Nurs Care Qual. 2009;24:109-115.

STUDY

Who's covering our loved ones: surprising barriers in the sign-out process.

Antonoff MB, Berdan EA, Kirchner VA, et al. Am J Surg. 2013;205:77-84.

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.

REVIEW

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

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

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.

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.

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

An institution-wide handoff task force to standardise and improve physician handoffs.

Horwitz LI, Schuster KM, Thung SF, et al. BMJ Qual Saf. 2012;21:863-871.

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.

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.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

COMMENTARY

Time to sign off on signout.

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

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.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

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

COMMENTARY

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.

Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360.

COMMENTARY

Implementing handoff communication.

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

STUDY

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

COMMENTARY

A theoretical framework and competency-based approach to improving handoffs.

Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. Qual Saf Health Care. 2008;17:11-14.

REVIEW

The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.

Foster S, Manser T. Acad Med. 2012;87:1105-1124.

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