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.
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
Guidelines for safe handoffs focus on standardizing the signout mechanism. 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. The seminal I-PASS study demonstrated that in a teaching hospital setting, implementation of a standardized handoff bundle—which included a mnemonic for standardized oral and written signouts, training in handoff communication, faculty development, and efforts to ensure sustainability—markedly reduced the incidence of preventable adverse events associated with handoffs. The I-PASS mnemonic stands for:
- Illness severity: one-word summary of patient acuity ("stable," "watcher," or "unstable")
- Patient summary: brief summary of the patient's diagnoses and treatment plan
- Action list: to-do items to be completed by the clinician receiving signout
- Situation awareness and contingency plans: directions to follow in case of changes in the patient's status, often in an "if—then" format
- Synthesis by receiver: an opportunity for the receiver to ask questions and confirm the plan of care
The I-PASS signout format is considered the gold standard for effective signout communication between physicians and has also been shown to improve the quality of nursing handoffs.
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.