7 steps to prevent medical errors during handoffs

By John Murphy
Published July 10, 2020

Key Takeaways

Thousands of patient handoffs happen every day—and every night—between primary care physician and specialist, between attending and resident, between day-shift nurse and night-shift nurse, and even by airlift between hospital and medical center. Handoffs are so commonplace, they should be as simple as crossing the street. Unfortunately, they’re not. 

“Far from being simple, mundane processes that sometimes lead to harm, handoffs are complex, exquisitely situated negotiations that, like most adaptations, produce both success and failure,” wrote the authors of a chapter on handoffs in the Handbook of Human Factors and Ergonomics in Health Care and Patient Safety.

Handoffs are common sources of miscommunication and medical error. An estimated 80% of serious medical errors involve miscommunication between caregivers during patient transfers, according to The Joint Commission. 

To improve communication and potentially reduce errors, here are 7 tips to help physicians make better handoffs. 

Talk face-to-face

The handoff should include the opportunity to ask questions and get answers about patient information. While face-to-face handoffs can’t happen in all circumstances, communicating live and in person is still the preferred method, experts say. 

Even though video calls have made remote communication easier, “the highest level of communication still occurs when we are face to face with someone,” Vineet Arora, MD, an expert on patient handoffs, explained to the American Medical Association. Dr. Arora is also an academic hospitalist and associate professor at the University of Chicago Medicine. 

When a face-to-face handoff isn’t available, email can be an acceptable substitute, provided that the receiver confirms receipt of the message, according to a committee opinion on handoffs from the American College of Obstetricians and Gynecologists (ACOG). 

“Voice mail or other unacknowledged messages, however, do not constitute an acceptable form of handoff,” the ACOG committee added. “The most effective handoff of patient information includes both verbal and written components.”

EHRs and novel electronic applications for facilitating handoffs can make the process easier and possibly reduce errors, but those are complementary to the handoff, not a substitute. Interpersonal communication between physicians is still the best way to handle the handoff. 

Avoid distractions

Find a calm setting, if possible, to make the handoff. Loud and busy places aren’t good locations for a complex and precise discussion about the critical transfer of a patient’s care. 

“For example, a noisy nursing station is a less desirable setting for communicating handoff information than a quiet conference room located away from other distractions. Having discussions in an environment without distractions will enhance communication during handoffs,” the ACOG committee advised. 

Make sure all patient info is up to date

Before making the handoff, make sure that all of the patient’s information is complete, accurate, and up to date. 

“Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information. Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries, among other outcomes,” Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, explained to Patient Safety Monitor

According to The Joint Commission, the critical information to share with the receiving caregiver should include, at a minimum: 

  • Sender’s contact information

  • Illness assessment, including severity

  • Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care

  • To-do action list

  • Contingency plans

  • Allergy list

  • Code status

  • Medication list

  • Dated laboratory tests

  • Dated vital signs

Don’t do an info dump

The short list above enumerates the minimum information to include in the handoff. On the other hand, providing an “info dump” of unnecessary information can be confusing and overwhelming to the caregiver who’s receiving the handoff. Focus on the information that’s most necessary to maintain the continuity of care. 

“An abundance of information produces a poverty of attention. Handoffs should not focus on comprehensiveness, but rather on salience,” wrote the authors in the Handbook of Human Factors and Ergonomics in Health Care and Patient Safety

Dr. Arora put it another way: “If it doesn’t relate to the anticipatory guidance, it’s probably okay to leave it on the written information and move on.” 

Communicate methodically

Pilots go through a checklist before takeoff. Similarly, physicians can go through a checklist during handoff. 

Standardized tools, structured protocols, and handy mnemonics are available to make the handoff more organized, consistent, and complete. An early one was the Situation-Background-Assessment-Recommendation (SBAR). A more recent mnemonic developed specifically for the handoff is I-PASS (which stands for Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver.)

Use familiar language

Language differences and misinterpretations can undercut accurate communication. Doctors from different backgrounds—even doctors from different departments or specialties—might have their own quirks in communicating. 

“Using standardized medical terminology avoids errors in communication that may occur when colloquialisms are used. The use of abbreviations, other than those that are well known and widely accepted, should be discouraged,” the ACOG committee recommended. “Awareness of cultural, professional, and gender differences in communication style is also an important factor in how clinical information is presented and received.”

Get verification

Communication is a two-way street. Errors in communication come not only from the speaker, but also from the listener. That’s why it’s important that the physician making the handoff ensures that the caregiver receiving the handoff has absorbed all of the necessary information. A nod and an “uh-huh” won’t cut it. 

Before the handoff is completed, verify that the receiving caregiver understands all the critical information—such as lab values, medication doses, urgent actions, etc—by asking them to repeat it back (or read it back) as necessary to avoid error, confusion, and misunderstanding.

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