Ironing Out The Kinks In Patient Care Handoffs

Miscommunication between healthcare practitioners poses a malpractice risk, especially when transferring the care of your patients. The process of communicating essential details of patient information in order to make sure care is continuous and safe is known as a “handoff.” If handoffs are poorly executed, the door opens for adverse events and possible lawsuits.

Patients are assessed and treated by many clinicians during an in-hospital course of care. Studies show that communication errors abound when multiple clinicians are contributing with observations, discussions and plans of care. Like the childhood game Telephone, clinician-to-clinician communication gaps cause information to be incorrectly relayed. The Joint Commission (TJC) reported over a decade ago that communication failures were among the primary causes of sentinel events in the hospital setting.1 More recent data from a survey in 2015 reveals that communication mistakes in healthcare organizations were to blame for approximately one-third of malpractice claims.2 Whether in the emergency room, upon admission, prior to surgery, upon discharge to a nursing home or at the medical office, being fully informed about patient care is imperative for the health and safety of your patient, and to reduce your risk.

Patients Weigh In

The Journal of Hospital Medicine conducted a 2016 study3 concerning patient experience with handoffs. Upon interview, most of the participant patients were unaware that a transition of care had taken place during their hospitalization. The study concluded that improved communication during handoffs is desired by patients, and improvement on a process would contribute to patient experience and satisfaction.

Communication Strategies to Improve Handoffs

  • Review your current handoff processes to identify need for updates.
  • Standardize the sign-out process within your healthcare facility. Consider tools such as checklists, templates or the SBAR technique. This may help providers establish a routine in hopes that they effectively communicate during each and every patient handoff.
  • Define roles for admitting physicians, hospitalists and specialty care physicians.
  • Communicate with other healthcare team members face-to-face and, if possible, in a quiet area.
  • Develop a standard set of critical elements of the patient’s clinical status that need to be communicated such as changes in patient management, condition decline, unit transfers, anticipated complications, etc. Your specialty will warrant specific communications.
  • Document the information exchange in the medical records in a thorough and timely manner.
  • If possible, in the emergency department or ICU, conduct the transition at the patient’s bedside so the oncoming physician can get a better understanding of the patient’s status. This also allows the patient’s family members who may be present to get involved.4
  • If you feel unclear about a patient’s status, review the medical record to get to the bottom of the “what,” “where” and “why” and, if needed, reach out to the provider.
  • Use caution at night when the overall pace seems to slow and the urge to wait with important communication seems appealing.4 Don’t delay communication.

I-PASS Handoff Program5

This method is intended to help reduce unexpected medical problems associated with sign-out communication.

  • Illness severity: one-word summary of patient acuity (“stable,” “watcher” or “unstable”)
  • Patient summary: brief summary of the patient’s diagnoses and treatment plan »» Action list: to-do items to be completed by the clinician receiving sign-out
  • Situation awareness and contingency plans: directions to follow in case of changes in the patient’s status, often in an “if-then” format
  • Synthesis by receiver: an opportunity for the receiver to ask questions and confirm the plan of care

  1. Communication During Patient Hand-Overs. Oakbrook, IL: Joint Commission, 2006, accessed May 1, 2019.
  2. CRICO Strategies. Medical Malpractice in America; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).
  3. A qualitative analysis of patients’ experience with hospitalist service handovers. J Hosp Med. 2016 Oct;11(10), accessed May 1, 2019.
  4. Standardization of Inpatient Handoff Communication. Jennifer A. Jewell, Committee on Hospital Care, Pediatrics, November 2016, Vol 138/ISSUE 5
  5. I-PASS Patient Safety Institute, The New Standard of Care for Patient Handoffs,