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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 Structured 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.

Several guidelines have been developed for implementing standardized signouts. One trial of a computerized and structured signout system in an academic medical center demonstrated improved efficiency and more time spent in direct patient care after implementation. Innovative signout strategies have incorporated practices from other industries, such as the adaptation of a signout strategy from Formula One auto racing to the handoff from operating room to intensive care unit. In nursing, the SBAR method (Situation-Background-Assessment-Recommendation) has become widely accepted not only as a signout tool but as a structured method for all communications between providers.

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
The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.
Panesar RS, Albert B, Messina C, Parker M. Am J Med Qual. 2014 Oct 1; [Epub ahead of print].
Resident to resident handoffs in the emergency department: an observational study.
Peterson SM, Gurses AP, Regan L. J Emerg Med. 2014 Sep 9; [Epub ahead of print].
Multidisciplinary in-hospital teams improve patient outcomes: a review.
Epstein NE. Surg Neurol Int. 2014;5(suppl 7):S295-S303.
Support from hospital to home for elders: a randomized trial.
Goldman LE, Sarkar U, Kessell E, et al. Ann Intern Med. 2014;161:472-481.
Coaching to improve the quality of communication during briefings and debriefings.
Kleiner C, Link T, Maynard MT, Halverson Carpenter K. AORN J. 2014;100:358-368.
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014 Sep 19; [Epub ahead of print].
Implications of Health Literacy for Public Health: Workshop Summary.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Editor's Picks for Handoffs and Signouts
From AHRQ WebM&M
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
What Have We Learned About Safe Inpatient Handovers?.
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. March 2011
 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 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 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.
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.
Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. J Hosp Med. 2006;1:257-266.
Handoffs causing patient harm: a survey of medical and surgical house staff.
Kitch BT, Cooper JB, Zapol WM, et al. Jt Comm J Qual Patient Saf. 2008;34:563-570.
 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.
Perioperative Patient 'Hand-Off' Tool Kit.
Association of Perioperative Registered Nurses.
Improving Transitions of Care: Hand-off Communications.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2014.
ACGME Duty Hours.
Accreditation Council for Graduate Medical Education.
Last Updated: October 2012