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Handoffs and Signouts
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Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, so patients will inevitably be cared for by many different providers during hospitalization. Nurses change shift every 8 to 12 hours, and, particularly at teaching institutions, multiple physicians may be responsible for a patient's care at different times of the day. This discontinuity creates opportunities for error when clinical information is not accurately transferred between providers. As one author put it, "for anyone who has watched children playing 'Telephone'…the inherent potential for error in signouts is obvious." The problems posed by handoffs of care have gained more attention since the 2003 implementation of regulations limiting housestaff duty hours, which has led to greater discontinuity among resident physicians.

Risk of error almost doubled when nurses worked ≥12.5 consecutive hours. 5% of shifts of 8 hours or less had a near error, and 2% had an error. 4% of shifts of between 8 and 12 hours had a near error, and 3% had an error. 7% of shifts of more than 12.5 hours had a near error, and 4% had an error.

Source: Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15:30-37. [go to PubMed]

The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient. (This Primer will discuss handoffs and signouts in the context of transfers of care during hospitalization. For information about safety issues at the time of hospital discharge, please see the related Patient Safety Primer Adverse Events after Hospital Discharge.)

Handoffs and signouts have been linked to adverse clinical events in settings ranging from the emergency department to the intensive care unit. One study found that being cared for by a covering resident was a risk factor for preventable adverse events; more recently, communication failures between providers have been found to be a leading cause of preventable error in studies of closed malpractice claims affecting emergency physicians and trainees. The seemingly straightforward act of communicating an accurate medication list is a well-recognized source of error. To avert this problem, hospitals are required to "reconcile" medications across the continuum of care. (For more information, see the related Primer "Medication Reconciliation.")

Implementing Effective Handoff and Signout Protocols

Current signout mechanisms are generally ad-hoc, varying from hospital to hospital and unit to unit. Guidelines for safe handoffs focus on standardizing the signout mechanism. The components of a safe and effective signout can be summarized using the acronym ANTICipate:

  • Administrative data (eg, patient's name, medical record number, and location) must be accurate. 
  • New clinical information must be updated. 
  • Tasks to be performed by the covering provider must be clearly explained. 
  • Illness severity must be communicated. 
  • Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in managing the patient overnight.

Efforts to improve the quality of clinical handoffs must enhance the quality of both written and verbal signouts. In addition to accurate and complete written signouts, effective handoffs require an environment free of interruptions and distractions, allowing for the clinician receiving the signout to listen actively and engage in a discussion when necessary. Although much effort has been put into standardizing and improving signout quality, firm data on the effectiveness of these protocols is lacking. Although computerized handoff tools are being widely implemented within electronic medical records, a systematic review found only weak evidence that they enhanced handoff quality and no evidence that they improved patient care outcomes. Promising approaches to improving the safety of clinical handoffs include standardized signouts as part of bundles such as teamwork training, standardized verbal communication, and electronic handoff tools, or formal checklists that specify key information for specific transitions in care.

Current Context

The Joint Commission requires all health care providers to "implement a standardized approach to handoff communications including an opportunity to ask and respond to questions" (2006 National Patient Safety Goal 2E). The Joint Commission National Patient Safety Goal also contains specific guidelines for the handoff process, many drawn from other high-risk industries

  • interactive communications 
  • up-to-date and accurate information 
  • limited interruptions 
  • a process for verification 
  • an opportunity to review any relevant historical data

The Accreditation Council for Graduate Medical Education also requires that residency programs maintain formal educational programs in handoffs and care transitions.

What's New in Handoffs and Signouts on AHRQ PSNet
Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults.
Callinan SM, Brandt NJ. J Gerontol Nurs. 2015;41:8-13.
Safely Home: What Happens When People Leave Hospital Care Settings?
London, UK: Healthwatch England; July 2015.
Bedside shift-to-shift handoffs: a systematic review of the literature.
Mardis T, Mardis M, Davis J, et al. J Nurs Care Qual. 2015 Jul 17; [Epub ahead of print].
Separating residents' inpatient and outpatient responsibilities: improving patient safety, learning environments, and relationships with continuity patients.
Bates CK, Yang J, Huang G, et al. Acad Med. 2015 Aug 4; [Epub ahead of print].
Test result communication in primary care: a survey of current practice.
Litchfield I, Bentham L, Lilford R, McManus RJ, Hill A, Greenfield S. BMJ Qual Saf. 2015 Aug 4; [Epub ahead of print].
Health information exchange in emergency medicine.
Shapiro JS, Crowley D, Hoxhaj S, et al. Ann Emerg Med. 2015 Jul 28; [Epub ahead of print].
Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center.
Smith CJ, Britigan DH, Lyden E, Anderson N, Welniak TJ, Wadman MC. J Hosp Med. 2015 Jul 22; [Epub ahead of print].
Editor's Picks for Handoffs and Signouts
From AHRQ WebM&M
What Have We Learned About Safe Inpatient Handovers?.
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. March 2011
Tacit Handover, Overt Mishap.
Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD. AHRQ WebM&M [serial online]. June 2010
All in the History.
Christopher Fee, MD. AHRQ WebM&M [serial online]. February/March 2009
Triple Handoff.
Arpana R. Vidyarthi, MD. AHRQ WebM&M [serial online]. September 2006
Fumbled Handoff.
Arpana Vidyarthi, MD. AHRQ WebM&M [serial online]. March 2004
 Classic iconRates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Review of computerized physician handoff tools for improving the quality of patient care.
Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2013;8:456-463.
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.
 Classic iconGraduate medical education and patient safety: a busy--and occasionally hazardous--intersection.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-598.
 Classic iconA randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.
Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. J Am Coll Surg. 2005;200:538-545.
 Classic iconHandoff strategies in settings with high consequences for failure: lessons for health care operations.
Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Int J Qual Health Care. 2004;16:125-132.
 Classic iconImproving Hand-Off Communication.
Oakbrook Terrace, IL: Joint Commission Resources; 2007. ISBN: 9781599400907.
Handoffs and fumbles.
Wachter RM, Shojania KG. In: Wachter RM, Shojania KG. Internal Bleeding. New York, NY: Rugged Land; 2004:159-180.
Improving Transitions of Care: Hand-off Communications.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.
Perioperative Patient 'Hand-Off' Tool Kit.
Association of Perioperative Registered Nurses.
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2015.
ACGME Duty Hours.
Accreditation Council for Graduate Medical Education.
Last Updated: December 2014