Improving handoffs in the emergency department.

Dickson S Cheung; John J Kelly; Christopher Beach; Ross P Berkeley; Robert A Bitterman; Robert I Broida; William C Dalsey; Heather L Farley; Drew C Fuller; David J Garvey; Kevin M Klauer; Lynne B McCullough; Emily S Patterson; Julius C Pham; Michael P Phelan; Jesse M Pines; Stephen M Schenkel; Anne Tomolo; Thomas W Turbiak; John A Vozenilek; Robert L Wears; Marjorie L White; American College of Emergency Physicians Section of Quality Improvement and Patient Safety

Commentary

Improving handoffs in the emergency department.

October 28, 2009

Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55(2):171-80.

View more articles from the same authors.

Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.

PubMed citation

Available at

Related Resources From the Same Author(s)

A survey of the use of time-out protocols in emergency medicine.

May 25, 2011

Procedural safety in emergency care: a conceptual model and recommendations.

October 24, 2012

Quality and safety implications of emergency department information systems.

July 17, 2013

Emergency medicine quality improvement and patient safety curriculum.

November 17, 2010

ACOG Committee Opinion #546: tracking and reminder systems.

December 12, 2012

ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.

April 30, 2014

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

December 16, 2009

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

April 22, 2009

Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.

July 24, 2013

Patient handoffs: standardized and reliable measurement tools remain elusive.

February 10, 2010

Using information technology to improve the quality and safety of emergency care.

July 6, 2011

Principles of pediatric patient safety: reducing harm due to medical care.

June 15, 2011

ACOG Committee Opinion #531: improving medication safety.

September 19, 2012

ACOG Committee Opinion #681: disclosure and discussion of adverse events.

January 30, 2005

Pediatric Readiness in the Emergency Department.

November 1, 2018

ACOG Committee Opinion #621: patient safety and health information technology.

April 1, 2015

Profiles in patient safety: confirmation bias in emergency medicine.

January 11, 2006

Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

October 10, 2012

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

December 5, 2018

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

June 29, 2011

Principles supporting dynamic clinical care teams: an American College of Physicians position paper.

September 25, 2013

Pediatric medication safety in the emergency department.

March 14, 2018

Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.

May 2, 2018

Studying the technical work of emergency care.

October 31, 2007

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

January 16, 2013

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.

June 5, 2013

Computer technology and clinical work: still waiting for Godot.

April 3, 2005

Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes.

February 22, 2012

What whiteboards in a trauma center operating suite can teach us about emergency department communication.

May 30, 2007

Longitudinal trends in U.S. drug shortages for medications used in emergency departments (2001–2014).

January 20, 2016

Improving patient safety by identifying side effects from introducing bar coding in medication administration.

October 19, 2005

Improving care transitions: current practice and future opportunities for pharmacists.

December 5, 2012

Incidence and types of non-ideal care events in an emergency department.

September 29, 2010

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

May 29, 2013

A patient reported approach to identify medical errors and improve patient safety in the emergency department.

November 23, 2016

Framework for patient safety research and improvement.

February 4, 2009

The role of automation in complex system failures.

May 11, 2005

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

May 28, 2014

Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients.

July 12, 2017

Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations.

March 18, 2015

Evaluation of a physician informatics tool to improve patient handoffs.

July 29, 2009

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

August 11, 2021

The use of simulation in emergency medicine: a research agenda.

March 7, 2007

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

August 16, 2006

Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.

March 27, 2005

John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.

March 6, 2005

Color coded medication safety system reduces community pediatric emergency nursing medication errors.

May 27, 2009

Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.

April 7, 2010

Economic evaluation of the impact of medication errors reported by US clinical pharmacists.

November 27, 2013

Exploring barriers and facilitators to the use of computerized clinical reminders.

April 21, 2005

Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods.

June 1, 2005

Measuring patient safety in the emergency department.

June 19, 2013

Personalised performance feedback reduces narcotic prescription errors in a NICU.

March 27, 2013

Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists.

August 5, 2009

An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions.

October 23, 2013

Developing expert medical teams: toward an evidence-based approach.

October 15, 2008

Case studies of patient safety research classics to build research capacity in low- and middle-income countries.

December 11, 2013

The outcomes card: development of a systems-based practice educational tool.

August 17, 2005

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.

April 17, 2019

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

Resilience and resilience engineering in health care.

July 30, 2014

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

March 9, 2011

Enhancing electronic health record usability in pediatric patient care: a scenario-based approach.

March 13, 2013

A model for improving health care quality for transgender and gender nonconforming patients.

January 23, 2020

Disclosure of medical errors: the right thing to do.

September 1, 2010

Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.

July 12, 2017

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

February 8, 2017

The science of human factors: separating fact from fiction.

May 22, 2013

Clinical care checklists: salvations or frustrations?

June 1, 2011

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

September 7, 2011

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Why don't we know whether care is safe?

April 10, 2013

Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences.

December 15, 2010

The development and implementation of checklists in obstetrics.

September 27, 2017

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

March 6, 2005

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

November 12, 2008

Medication errors in pediatric inpatients: prevalence and results of a prevention program.

September 17, 2008

Process indicators of quality clinical pharmacy services during transitions of care.

December 12, 2012

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

Using a network organisational architecture to support the development of Learning Healthcare Systems.

February 21, 2018

The effect of race and sex on physicians' recommendations for cardiac catheterization.

July 15, 2002

Handoff strategies in settings with high consequences for failure: lessons for health care operations.

March 6, 2005

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

November 25, 2015

Another look at medical error.

March 6, 2005

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

May 22, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

Hospital-wide code rates and mortality before and after implementation of a rapid response team.

December 10, 2008

Simulation in graduate medical education 2008: a review for emergency medicine.

August 13, 2008

Improving the accuracy of patient identification in the medication-use process.

February 8, 2006

The Armstrong Institute: an academic institute for patient safety and quality improvement, research, training, and practice.

June 10, 2015

Assessment of physician sleep and wellness, burnout, and clinically significant medical errors.

January 13, 2021

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

March 14, 2012

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care.

March 17, 2021

Impact of senior clinical review on patient disposition from the emergency department.

April 28, 2010

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network.

September 23, 2015

Priorities for pediatric patient safety research.

February 13, 2019

Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.

August 13, 2008

Related Resources

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

September 6, 2023

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

August 23, 2023

Improving emergency medicine clinician awareness of prehospital-administered medications.

August 9, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Closed-loop communication in interprofessional emergency teams: a cross-sectional observation study on the use of closed-loop communication among anesthesia personnel.

March 22, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

WebM&M Cases

Miscommunication During the Interhospital Transport of a Critically Ill Child

August 31, 2022

Who killed patient safety?

July 20, 2022

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019.

April 27, 2022

Patient Safety Innovations

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

April 7, 2022

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

February 17, 2021

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication.

June 3, 2020

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients.

March 11, 2020

Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting: a systematic review.

August 7, 2019

The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication.

May 29, 2019

WebM&M Cases

Updates in the Management of High-Risk Pulmonary Embolism

May 1, 2019

Does a unit shift report "blackout" period improve patient safety?

April 10, 2019

WebM&M Cases

Duplicate Insulin Order

March 1, 2019

WebM&M Cases

Triaging Interhospital Transfers

February 1, 2019

Implementing bedside handoff in the emergency department: a practice improvement project.

January 23, 2019

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment.

December 5, 2018

Pediatric medication safety in the emergency department.

March 14, 2018

Medication errors in injured patients.

September 27, 2017

Handoffs: transitions of care for children in the emergency department.

January 25, 2017

See More About The Topic

Emergency Departments

Health Care Providers

Health Care Executives and Administrators

Safety Scientists

Emergency Medicine

Improving handoffs in the emergency department.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving handoffs in the emergency department.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site