• Study
  • Published November 2009

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.

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