Communication, Challenges and Opportunities During Handoffs

Richard M Frankel, Professor, Medicine and Geriatrics, Senior Research Scientist Regenstrief Institute Indiana University School of Medicine, USA

Amber Welsh, Patient Safety fellow Roudebush VAMC, USA

Orit Karnieli-Miller, Postdoctoral fellow Indiana School of Medicine and Regenstrief Institute, Indianapolis, USA

Variations in communication during patient handoffs cause a significant number of errors and “near misses” to occur, leading to adverse outcomes and sub-optimal care. The research interest in this area has been growing steadily.

In medical care, a handoff (also known as sign-out or end-of-shift report) refers to information about a patient that is transferred by one professional or a team to another. “The primary objective of a ‘handoff’ is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes1.” The number and types of handoffs for any given hospitalised patient can vary and may involve physicians, nurses, pharmacists, transport, and even food service.

Handoffs are not simply a mechanical means for transmitting and receiving information. In medical care, a handoff requires that the sender consider a patient’s present condition and his / her likely future over the next 8-12 hours; likewise, the receiver must comprehend what is being transmitted and feel confident about the clarity and reliability of the message. Thus, in addition to sheer information exchange, handoffs also involve the transfer of rights, duties and obligations as they relate to the meaning and interpretation of communication from one professional to another.

Interest in handoffs has grown steadily over the past decade as researchers, hospital administrators, educators and policy makers have learned that variations in communication during patient handoffs cause significant number of errors and “near misses” to occur, leading to adverse outcomes and suboptimal care. According to the Institute of Medicine (IOM), up to 98,000 patients die and another 15 million are harmed in US hospitals annually due to medical errors2. Root cause analysis of reported sentinel events from 1994 to 2004 reveals that two-thirds of these errors were due to communication failures1,3.

Another reason for increased interest in handoffs is related to the adoption of duty restriction hours by the Accreditation Council for Graduate Medical Education (ACGME) that has dramatically increased the number of care transfers that take place among resident physicians during a typical hospital stay. The increased number of handoffs results in a parallel increase in the potential for near misses and errors and worsened quality of care. Residents and attending physicians have expressed concerns that the increased number of handoffs results in loss of critical information and continuity of care4.

It is no secret that medical care in the US is fragmented. Often this is reflected in the patient’s experience of care as a series of confusing and sometimes conflicting communication exchanges with different types of healthcare providers, a situation in which “the left hand does not seem to know what the right hand is doing.” The lack of integration is also reflected in the fact that handoffs vary in approach and content across medical specialties, professional roles and sometimes even between shifts on a single service. Added to the fact that medicine and nursing handoffs typically occur in parallel; without any cross communication, it is little wonder that patients experience care as discontinuous and fragmented.

Recognising the importance of improving inpatient handoff processes, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2006 implemented a new requirement as part of National Patient Safety Goal No. 2, to “Improve the effectiveness of communication among caregivers5.” Requirement 2E requires facilities to “implement a standardised approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.” Notably, JCAHO requirements did not specify how a standardised approach was to be achieved. Instead each individual healthcare facility or health system was left to its own to address the requirements. While this is a good first step, it leaves open the question of developing generalised standards and evaluation metrics for handoffs.

In many high reliability industries outside of medicine, such as aerospace, nuclear power and recombinant DNA research, handoffs are critical and mistakes can be fatal6,7. In these industries, handoff skills are formally taught and practised repetitively, often using simulation and other educational techniques to optimise precision and anticipate errors. Research in these industries has shown that there are structured communication techniques that increase reliability and reduce the likelihood of misunderstanding and error. Unfortunately, these principles have not been transferred into medicine to any great degree. A recent study of handoffs that included a national survey of medical schools found that a mere 8% teach the handoff as formal part of the curriculum. This leaves students to observe and learn from those above them in the medical hierarchy. If residents and attending physicians perform handoffs poorly, risky and unreliable habits of practice may be transmitted through the “informal” or “hidden” curriculum of medicine from one cohort of students to the next.

The haphazard nature of inpatient handoffs has been reported in case studies8,9 as well as through empirical analyses. In a matched case-control study of inpatient adverse events, the likelihood of preventable adverse events was significantly higher under the care of a cross-covering physician than under the admitting care team10. Similarly, patients admitted to the hospital by a cross-covering physician (rather than the primary physician) had longer inpatient stays and more laboratory tests11. In a study using critical incident and interview techniques, Arora et al.12 linked communication failures in handoffs in a sample of residents to adverse events, highlighting problem areas of missing content or errors in process (e.g. no face-to-face communication, illegible handwriting). Another study’s findings indicate that handoffs may lack information that could potentially affect patient care, such as anticipated patient events13.

A recent pilot study conducted by our research team suggests that there are various social, linguistic and technological factors that might contribute to a near miss or adverse event during a handoff. These factors may include: interruptions (e.g. people talking during a handoff, coming in and out of the room); unclear audio-taping or unreadable handwriting; lack of time to listen to all the reports (“running off” to the shift); inaccurate descriptions of (e.g. “the patient is listed as DNR and he’s not,”); lack of information provided, omitted information; gaps between rules and regulations and the actual handling of the handoff (e.g. listening to the handoff and only then reading the forms without the opportunity to ask clarification questions); second order handoffs (e.g. charge nurse summarises the patient’s report); and various behaviours that might negatively affect the ability to listen and absorb the information (e.g. not writing down information, eating, having parallel conversations)14.

A further complexity in handoffs is the rapid spread of electronic medical records and the use of computer based tools13. While these tools provide greater flexibility and access to data necessary for effective care, they also potentially reduce the amount of face-to-face contact time used to conduct handoffs, a feature recognised as critical for effective handoffs in virtually all high-reliability industries7,15. Moreover, the face-to-face conversation during handoffs is highly complex and nuanced16. This complexity is due to a number of factors, including the number of patients involved in the handoff, the complexity and criticality of patients’ conditions, competing demands, time pressures and contextual cues (sights, smells, sounds) nearby the exchange.

Recent scholarship based on handoffs across a variety of high reliability organisations has produced a set of generalised handoff strategies that are associated with improved reliability and outcomes7,17,15,18. These include being face to face, choosing a location that is quiet with no interruptions, the use of checklist procedures and “teach backs” or “talk backs” (i.e. the receiver of the information repeats it), to ensure that the intention and effect of a message have been heard and understood across an authority or power gradient19. It is only when the content of the message has been repeated that the action contained in a request typically takes place. In medicine, checking for understanding of content, is rare. For example, a 1999 study by Braddock and colleagues looking at several dimensions of informed decision making showed that primary care physicians and surgeons assessed patient understanding an average of 1.5% of the time20. Recent attempts to improve communication using standardised protocols such as Situation, Background, Assessment, and Recommendation (SBAR) and systematic training have shown promising results in physician and nurse handoffs21.

Handoff research in medicine is in its infancy. There is a need to better understand the range of ways that handoffs occur within and across professional roles. As well, there is a need to incorporate what we know from other high reliability organisations and apply them to medical care. Given the complexity of healthcare, some may translate more easily than others. Research suggests that there is a pressing need for better education in medicine, nursing and pharmacy about how to conduct high reliability handoffs. Continued fragmentation of care can only lead to increased risk of adverse events and “near misses”. Finally, the impact of the electronic medical record and information technology on handoffs deserves greater study. There will undoubtedly be increased costs associated with improving the reliability of transfers of medical care. Ultimately, the question is not whether we can afford to underwrite these costs but whether we can afford not to.


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