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 (153)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (17)

•Medical Complications (3)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (21)

•Psychological and Social Complications (2)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (6)

Resource Types

•Journal Article (137)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newspaper/Magazine Article (13)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

•Web Resource (4)

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 (138)

•Nursing (24)

•Pharmacy (4)

Target Audience

•Health Care Providers (131)

•Health Care Executives and Administrators (130)

•Non-Health Care Professionals (38)

•Patients (4)

Setting of Care

•Hospitals (145)

•Residential Facilities (1)

•Ambulatory Care (10)

•Outpatient Surgery (1)

•Patient Transport (8)

1 - 20 of 167

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COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.

Boat AC, Spaeth JP. Paediatr Anaesth. 2013 May 18; [Epub ahead of print].

COMMENTARY

DNR in the OR and Afterwards

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

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

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

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

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

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

COMMENTARY

2009 National Patient Safety Goals.

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

STUDY

Bridging gaps in handoffs: a continuity of care based approach.

Abraham J, Kannampallil TG, Patel VL. J Biomed Inform. 2012;45:240-254.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

COMMENTARY

Standardizing hand-off processes.

Crum Gregory BS. AORN J. 2006;84:1059-1061.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

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

TOOLKIT

Perioperative Patient 'Hand-Off' Tool Kit.

Association of Perioperative Registered Nurses.

MULTI-USE WEBSITE

Care Transitions Program.

Aurora, CO: The Division of Health Care Policy and Research, University of Colorado Health Sciences Center.

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].

REVIEW

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

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

REVIEW

Information transfer and communication in surgery: a systematic review.

Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.

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.

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