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Handoffs and Signouts

Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.

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Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.

September 7, 2019

Background

A handoff is the process of one healthcare provider updating another of the status of one or more patients for the purpose of handing over responsibility for their care. This can include a physician updating another at the change of shift or a nurse transitioning a patient from her department to another.

This Primer will discuss handoffs 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 Primers Adverse Events after Hospital Discharge and Post-Acute Transitional Services: Safety in Home-Based Care Programs.

Handoffs 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 Protocols

Guidelines for safe handoffs focus on standardizing the process. Efforts to improve the quality of clinical handoffs must enhance the quality of both written and verbal communication. In addition to accurate and complete written information, effective handoffs require an environment free of interruptions and distractions, allowing for the clinician receiving the handoff 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 information, 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.

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.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.