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

Brian Hilligoss; Jerry A. Mansfield; Emily S. Patterson; Susan D. Moffatt-Bruce

Commentary

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

March 18, 2015

Hilligoss B, Mansfield JA, Patterson ES, et al. Jt Comm J Qual Patient Saf. 2015;41(3):134-143.

View more articles from the same authors.

Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.

PubMed citation

Available at

Related Resources From the Same Author(s)

The limits of checklists: handoff and narrative thinking.

June 25, 2014

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

August 11, 2021

Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response.

April 1, 2015

Cultural transformation after implementation of crew resource management: is it really possible?

July 27, 2016

Patient safety: disclosure of medical errors and risk mitigation.

August 3, 2016

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

July 12, 2017

Leadership oversight for patient safety programs: an essential element.

January 17, 2018

Another surgeon's error: must you tell the patient?

October 15, 2014

Investigating the causes of adverse events.

June 7, 2017

Preventing wrong site, procedure, and patient events using a common cause analysis.

August 31, 2011

IDEA4PS: the development of a research-oriented learning healthcare system.

February 14, 2018

Patient safety strategies: are we on the same team?

October 3, 2012

Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.

June 12, 2019

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.

August 13, 2014

Improving medication administration safety in solid organ transplant patients through barcode-assisted medication administration.

August 14, 2013

The link between clinically validated patient safety indicators and clinical outcomes.

January 10, 2018

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

November 16, 2016

Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety.

September 14, 2016

What is the return on investment for implementation of a crew resource management program at an academic medical center?

October 14, 2015

Effect of barcode-assisted medication administration on emergency department medication errors.

October 2, 2013

The published literature on handoffs in hospitals: deficiencies identified in an extensive review.

May 5, 2010

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

May 2, 2018

Patient handoffs: standardized and reliable measurement tools remain elusive.

February 10, 2010

The underappreciated role of habit in highly reliable healthcare.

September 23, 2015

Navigating care transitions: a process model of how doctors overcome organizational barriers and create awareness.

March 25, 2015

A handoff is not a telegram: an understanding of the patient is co-constructed.

March 7, 2012

Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.

September 24, 2014

Retained surgical items: a problem yet to be solved.

October 31, 2012

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

October 19, 2005

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

July 24, 2013

"At home, with care": lessons from New York City home-based primary care practices managing COVID-19.

December 16, 2020

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

May 28, 2014

No harm found when nurse anesthetists work without supervision by physicians.

August 11, 2010

Evaluation of a physician informatics tool to improve patient handoffs.

July 29, 2009

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

High-risk, high-alert medication management practices in a regional state psychiatric facility.

May 9, 2007

Sleep quality and fatigue among prehospital providers.

April 7, 2010

Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010.

January 25, 2017

Using a quantitative risk register to promote learning from a patient safety reporting system.

February 4, 2015

Morbidity and mortality conference in emergency medicine residencies and the culture of safety.

December 9, 2015

Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.

March 18, 2015

Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety.

February 12, 2014

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

June 1, 2005

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

April 21, 2005

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.

August 10, 2016

The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

October 22, 2014

Safety-I, Safety-II and resilience engineering.

November 6, 2015

Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs.

August 28, 2013

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

May 11, 2022

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

October 19, 2011

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

April 17, 2019

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.

November 2, 2016

Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors.

May 14, 2014

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

March 13, 2013

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

September 21, 2016

Parent willingness to remind health care workers to perform hand hygiene.

August 14, 2013

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

August 27, 2014

Dental patient safety in the military health system: joining medicine in the journey to high reliability.

August 7, 2019

Patterns in outpatient benzodiazepine prescribing in the United States.

February 13, 2019

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

February 4, 2015

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

April 4, 2007

Dispensing errors and counseling quality in 100 pharmacies.

July 15, 2009

Medical errors arising from outsourcing laboratory and radiology services.

September 19, 2007

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

April 7, 2010

AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.

October 21, 2009

Health plan members' views about disclosure of medical errors.

March 6, 2005

Improved incident reporting following the implementation of a standardized emergency department peer review process.

June 11, 2014

Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors.

February 8, 2006

When staff speak up on safety, do managers listen—and act?

August 24, 2011

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

March 6, 2005

The association between EMS workplace safety culture and safety outcomes.

October 19, 2011

Electronic medication reconciliation and medication errors.

September 2, 2015

Evaluation of drug interaction software to identify alerts for transplant medications.

March 6, 2005

Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

September 25, 2013

Perioperative safety in plastic surgery: is the World Health Organization checklist useful in a broad practice?

April 22, 2015

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

January 6, 2016

Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors.

May 9, 2018

Mistakes and disclosure.

April 23, 2008

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

June 1, 2011

Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system.

June 20, 2018

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training.

May 1, 2013

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

February 13, 2008

Rapid response systems: from implementation to evidence base.

November 3, 2010

When clinicians drop out and start over after adverse events.

March 14, 2018

Dangerous deception--hiding the evidence of adverse drug events.

November 29, 2006

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

August 20, 2014

On the prospects for a blame-free medical culture.

November 4, 2009

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.

May 30, 2018

Implementation of a rapid response team: a success story.

June 17, 2009

What causes adverse events in prehospital care? A human-factors approach.

September 19, 2012

The evolution of a safety culture.

October 7, 2015

When the bone flap hits the floor.

October 18, 2006

Documentation of clinical review and vital signs after major surgery.

October 29, 2008

Clinical decision support and malpractice risk.

July 13, 2011

Care at the point of impact: insights into the second-victim experience.

May 18, 2016

PCA safety data review after clinical decision support and smart pump technology implementation.

June 12, 2013

Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations.

November 30, 2016

Consumer rankings and health care: toward validation and transparency.

October 12, 2016

Related Resources

'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.

December 6, 2023

Work system barriers and facilitators of a team health information technology.

September 13, 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

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

May 31, 2023

Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department.

May 31, 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

EMS Perils from Hospital Overcrowding

August 31, 2022

WebM&M Cases

Miscommunication During the Interhospital Transport of a Critically Ill Child

August 31, 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

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

The standardisation of handoffs in a large academic paediatric emergency department using I-PASS.

July 28, 2021

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

Racial bias among emergency providers: strategies to mitigate its adverse effects.

May 26, 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

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 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

See More About The Topic

Emergency Departments

Health Care Executives and Administrators

Emergency Medicine

Discontinuities, Gaps, and Hand-Off Problems

Epidemiology of Errors and Adverse Events

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

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

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

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

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