The process for transferring a patient from one provider to another can cause serious injury if information falls through the cracks.

“Handoff” is the term used when a patient is being transitioned for care by another provider, team, or service.  As medical care becomes increasingly specialized, more providers may be caring for a patient.  With more clinicians on a team, the possibility of a communication error between shifts—or specialties—increases.   

The Joint Commission identifies inadequate handoffs as a “longstanding, common problem in healthcare.” The Commission defines handoff as “a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.”  While providing information to an incoming caregiver sounds easy, in practice, there are many stumbling blocks to effective handoff.  Just a few include poor documentation, inadequate training, language barriers, and more.

In a recent study in the Journal of Patient Safety, researchers reviewed a random sample of medical malpractice claims between the years 2001 and 2011 provided by CRICO, a professional liability insurer for the Harvard medical community.  The findings were compelling:

  • In 49 percent of the claims, communication failures were reported.
  • Medical malpractice claims involving communication faults were less likely to be dismissed or dropped.
  • Of claims involving communication failure, 53 percent involved miscommunication between the patient and the provider. The other 47 percent of these claims involved communication failure between providers.
  • Types of information commonly miscommunicated included the severity the condition of the patient, diagnosis, and contingency plans.
  • Of these communication failures, 40 percent involved failed handoff.  Study authors estimate 77 percent of these claims could have been prevented by using a handoff tool.

The Joint Commission estimates there may be 4,000 handoffs every day in a standard teaching hospital.  The steps suggested by the Commission to reduce failed handoff include:

  • Top-down commitment by leadership to focus on a systematic approach to successful handoff rather than dwelling on individual error
  • Standardize information to be communicated during handoff, including mnemonics or handoff tools to bolster the process
  • Consider multiple handoff avenues such as paper and electronic communication, and requiring face to face, telephone, or screen handoff
  • Conduct handoff without interruption and include team or family members as appropriate
  • Provide adequate and ongoing training on handoff
  • Monitor and revise the system as needed

Best practices mean better outcomes. Without attention to the overall process by which providers transfer patient care, communication failure during patient handoff will continue to cause patient harm—and heartbreak.

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