AHRQ Patient Safety Network

The Collection > Structured Hand-offs

PATIENT SAFETY PRIMERS
Handoffs and Signouts

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (6)

•Identification Errors (1)

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

•Fatigue and Sleep Deprivation (2)

•Medication Safety (16)

•Medical Complications (3)

•Surgical Complications (21)

•Psychological and Social Complications (2)

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•Asia (1)

•Australia and New Zealand (10)

Resource Types

•Journal Article (147)

•Legislation/Regulation (2)

•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 (34)

•Latent Errors (23)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (148)

•Nursing (26)

•Pharmacy (2)

Target Audience

•Health Care Providers (142)

•Health Care Executives and Administrators (144)

•Non-Health Care Professionals (41)

•Patients (5)

Setting of Care

•Hospitals (155)

•Residential Facilities (3)

•Ambulatory Care (10)

•Patient Transport (9)

1 - 20 of 184

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STUDY

Pharmacist medication assessments in a surgical preadmission clinic.

Kwan Y, Fernandes OA, Nagge JJ, et al. Arch Intern Med. 2007;167:1034-1040.

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.

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

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.

STUDY

Multitasking during patient handover in the recovery room.

van Rensen EL, Groen ES, Numan SC, et al. Anesth Analg. 2012;115:1183-1187.

TOOLKIT

Perioperative Patient 'Hand-Off' Tool Kit.

Association of Perioperative Registered Nurses.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

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.

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].

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

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

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

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.

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.

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].

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

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.

STUDY

Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.

Greenstein EA, Arora VM, Staisiunas PG, Banerjee SS, Farnan JM. BMJ Qual Saf. 2013;22:219-224.

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

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.

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