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 (172)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (17)

•Medical Complications (2)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (20)

•Psychological and Social Complications (3)

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•Asia (1)

•Australia and New Zealand (10)

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•Journal Article (148)

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•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 (33)

•Active Errors (34)

•Latent Errors (24)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (148)

•Nursing (27)

•Pharmacy (3)

Target Audience

•Health Care Providers (141)

•Health Care Executives and Administrators (143)

•Non-Health Care Professionals (43)

•Patients (5)

Setting of Care

•Hospitals (155)

•Residential Facilities (3)

•Ambulatory Care (10)

•Outpatient Surgery (1)

•Patient Transport (9)

1 - 20 of 184

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STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

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

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

STUDY

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

Hess DR, Tokarczyk A, O’Malley M, Gavaghan S, Sullivan J, Schmidt U. Chest. 2010;138:1475-1479.

STUDY

ED handoffs: observed practices and communication errors.

Maughan BC, Lei L, Cydulka RK. Am J Emerg Med. 2011;29:502-511.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

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

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.

COMMENTARY

Time to sign off on signout.

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

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

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

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

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-2912.

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.

COMMENTARY

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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