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PSNet: Patient Safety Network
Journal Article

Handoffs causing patient harm: a survey of medical and surgical house staff.

Kitch BT, Cooper JB, Zapol WM, et al. Joint Commission journal on quality and patient safety. 2008;34:563-70.

The importance of standardized handoff communications in preventing errors is underscored by its inclusion as a National Patient Safety Goal, and specific guidelines have been developed to promote safe handoff practices. Despite this, multiple studies demonstrate that signout practices are still suboptimal, particularly at academic hospitals. Further corroborating evidence is supplied by this survey of medical and surgical residents at a teaching hospital. The majority of residents reported witnessing patient harm due to inadequate signouts, and signout practices often did not conform to recommended guidelines—specifically, signouts were often conducted over the phone or were subject to frequent interruptions. An AHRQ WebM&M commentary discusses a case of an inadequate signout that resulted in an adverse event.