Background

The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff.^1–3 An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the effects of ineffective handoffs: adverse events and patient safety risks.^4–11 The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first”¹² (p. 45). This chapter presents an overview of handoffs, a summary of selected literature, gaps in the knowledge, and suggestions for quality improvement initiatives and recommendations for future research.

What Is a Handoff?

First one needs to recognize the term “handoff” and synonymous terms that are used in a wide variety of contexts and clinical settings. There are a number of terms used to describe the handoff process, such as handover,^{1, 13, 14} sign-out,^{15, 16} signover,¹⁷ cross-coverage,^{18, 19} and shift report.^20–22 For the purpose of this discussion, the term “handoff” will be used and defined as, “The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm”²³ (p. 31). The concept of a handoff is complex and “includes communication between the change of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care”¹ (p. 1). The handoff is also “a mechanism for transferring information, primary responsibility, and authority from one or a set of caregivers, to oncoming staff”¹⁷ (p. 1). So, conceptually, the handoff must provide critical information about the patient, include communication methods between sender and receiver, transfer responsibility for care, and be performed within complex organizational systems and cultures that impact patient safety. The complexity and nuance of the type of information, communication methods, and various caregivers for each of these factors impact the effectiveness and efficiency of the handoff as well as patient safety.

Why Is There a Problem With Handoffs Today?

As health care has evolved and become more specialized, with greater numbers of clinicians involved in patient care, patients are likely to encounter more handoffs than in the simpler and less complex health care delivery system of a few generations ago.¹¹ Ineffective handoffs can contribute to gaps in patient care and breaches (i.e., failures) in patient safety, including medication errors,^{19, 24} wrong-site surgery,⁹ and patient deaths.^{4, 7} Clinical environments are dynamic and complex, presenting many challenges for effective communication among health care providers, patients, and families.^25–27 Some nursing units may “transfer or discharge 40 percent to 70 percent of their patients every day”²⁸ (p. 36), thereby illustrating the frequency of handoffs encountered daily and the number of possible breaches at each transition point.

Our expanding knowledge base and technological advances in health care spawn additional categories of health care providers and specialized units designed for specific diseases, procedures, and phases of illness and/or rehabilitation. This dynamic, ever-increasing specialization, while undertaken to improve patient outcomes and enhance health care delivery, can contribute to serious risks in health care delivery and promote fragmentation of care and problems with handoffs.^{3, 10, 29} It is ironic that as health care has become more sophisticated due to advances in medical technology focused on saving lives and enhancing the quality of life, the risks associated with the handoffs have garnered attention in the popular press³⁰ and reports from health care organizations and providers.^{3, 4, 6, 10, 31–35} The hazard that “fumbled handoffs”^{7, 10} pose to patient safety and the delivery of quality health care cannot be ignored. Ineffective handoffs can lead to a host of patient safety problems; research¹ and development of strategies to reduce these problems are required.^{33, 34}

What contributes to fumbled handoffs? An examination of how communication breakdown occurs among other disciplines may have implications for nurses. A study of incidents reported by surgeons found communication breakdowns were a contributing factor in 43 percent of incidents, and two-thirds of these communication issues were related to handoff issues.³⁶ The use of sign-out sheets for communication between physicians is a common practice, yet one study found errors in 67 percent of the sheets.¹⁵ The errors included missing allergy and weight, and incorrect medication information.¹⁵ In another study, focused on near misses and adverse events involving novice nurses, the nurses identified handoffs as a concern, particularly related to incomplete or missing information.³⁷

Acute care hospitals have become organizationally complex; this contributes to difficulty communicating with the appropriate health care provider. Due to the proliferation of specialties and clinicians providing care to a single patient, nurses and doctors have reported difficulty in even contacting the correct health care provider.³⁸ One study found that only 23 percent of physicians could correctly identify the primary nurse responsible for their patient, and only 42 percent of nurses could identify the physician responsible for the patient in their care.³⁹ This study highlights the potential gaps in communication among health care providers transferring information about care and treatment.

A handoff is largely dependent on the interpersonal communication skills of the caregiver³³ as well as the knowledge and experience level of the caregiver. There is reported variability in quality,⁴⁰ lack of structure in how handoffs usually occur,³³ and variances in shift handoffs.^{22, 41–43} Concern has been raised that the transition of care between providers during handoffs will continue to be problematic as research indicates that “only 8 percent of medical schools teach how to hand off patients in formal didactic session”³ (p. 1097), creating a large educational gap in new professionals and persistence of traditional models. Physicians and nurses communicate differently. Nurses are focused on the “big picture” with “broad and narrative”⁴⁴ (p. i86) descriptions of the situation, whereas physicians are focused on bullets of critical information.⁴⁴ A technique that seeks to bridge the gap between the different communication styles of nurses and physician is the situation, background, assessment, recommendation (SBAR) briefing model⁴⁴ that is being used successfully to enhance handoff communication.⁴⁵

The issue of handoffs has become so prominent that the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCAHO) introduced a national patient safety goal on handoffs that became effective in January 2006.⁴⁵ The national safety goals, developed by the Joint Commission with input from the Sentinel Event Advisory Group, identify new actions with the potential to protect patient safety.⁴⁶ The patient safety goal requires health care organizations to “implement a standardized approach to “handoff” communications, including an opportunity to ask and respond to questions.”⁴⁷ While the goal is simply stated, it is challenging to develop and implement effective strategies for handoffs across various health care settings, given the complexity of health care delivery. The Joint Commission’s guidelines for implementation of the safety goal are presented in Table 1,⁴⁸ and suggested strategies for effective handoffs are listed in Table 2.

Table 1

Joint Commission 2008 Hospital Patient Safety Goals Implementation Expectations for Handoffs

Table 2

Strategies to Improve Handoff Communication

Following are examples of each of these handoff expectations:

1. Nurse Brown on unit A is receiving report from Nurse Green who is transferring the patient from unit B to unit A. The patient medication administration record (MAR) does not indicate the patient has received any pain medication in the past shift. When Nurse Brown asks about this, Nurse Green realizes she gave morphine sulfate but did not document it on the MAR. Due to Nurse Brown’s question, Nurse Green realizes the omission and communicates the information and documents it in the medical record, preventing an accidental overdose of a medication.
2. A patient who had undergone a surgical procedure has not been out of bed since being transferred to the nursing unit. The offgoing nurse alerts the oncoming nurses that the patient will need help getting out of bed, possibly preventing a patient fall.
3. Handoffs require a process for verification of the received information, including read back, as appropriate. For example, the receiver of the telephone message regarding a laboratory value is asked to write it down and read the message back, including the name of the patient, the test, and the test result/interpretation.^{49, 50} Information to be recorded should also include the name and credentials of sender and receiver and the date and time.⁵⁰
   Laboratory Technician: I am calling with the lab results on Mr. Green.
   Nurse: Let me get a notepad. You are calling the lab results for Mrs. Marie White?
   Laboratory Technician: No, I am calling results for Mr. Tom Green ID #12345678. Mr. Green’s potassium level is 5.1, which was drawn at 0700 today.
   Nurse: You reported that Mr. Tom Green’s potassium level is 5.1. This is Nancy Jones, RN.
   Laboratory Technician: Thank you, Nancy. That is correct; Mr. Tom Green’s potassium level is 5.1 This is Bill Smith, lab tech.
4. The receiver of the handoff information has an opportunity to review relevant patient/client/resident historical data, which may include previous care, treatment, and services. A patient has been transferred, and the nurse notes several omissions from previous medication orders, including insulin. The nurse notifies the physician and obtains correct and complete medication orders, thereby avoiding a potentially serious medication error.
5. A nursing unit schedules staffing coverage to accommodate the shift change and minimize the occurrence of interruptions during change-of-shift report. Ancillary staff does not leave the nursing unit until report is completed to assure phones are answered and timely responses to call lights are made so nurses can provide report effectively and efficiently.

It is important to understand the context in which care is provided and be cognizant of the impact of the environmental processes on health care providers. The physical work environment may not be conducive to effective handoffs as it may be noisy^{58, 59} and prone to interruptions, (i.e., pagers, phone calls),^60–63 and the handoff may be conducted under physical and emotional pressures.¹¹ A study examining communication patterns among physicians and nurses found thirty one percent of communication exchanges involved interruption, translating into roughly 11 interruptions an hour for physicians and nurses.⁶⁰ Spencer and colleagues⁶² found 15 interruptions per hour. Barriers to transmission of accurate information in a patient transfer include incomplete medical record, lack of complete information provided by nurses, and the omission of essential information.⁶⁴ Handoffs are compromised if critical pieces of information are omitted because of difficulties with data access^{4, 29} or if documentation is illegible^{31, 33} or not transferred.⁵⁵ Despite efforts to promote the use of electronic patient records, according to a 2002 survey, less than 10 percent of hospitals have complete access to electronic systems such as computerized physician order entry (CPOE).⁶⁵

The ever-increasing abundance of data requires that health care providers synthesize and make decisions using large amounts of complex information. Unfortunately, data quickly degrades; for example, critically ill patients have many clinical parameters that are being monitored frequently.⁶⁶ Decisions need to be based on trends in the data and current information, which is essential to making informed decisions.⁶⁶ Tremendous amounts of information are constantly being generated, such as monitored clinical parameters, diagnostic tests, and multidisciplinary assessments. When this large amount of information is combined with the numerous individuals—clinical and nonclinical—who come in contact with a patient during a treatment episode and data transmission, not all members of the health care team may be aware of all the information pertinent to each patient.⁶⁶

In an effort to compress information and make it manageable among health care providers, handoffs may result in a “progressive loss of information known as funneling, as certain information is missed, forgotten or otherwise not conveyed” ⁶⁶ (p. 211). The omission of information or lack of easy accessibility to vital information by health care providers can have devastating consequences.^{4, 11} Such gaps in health care communication can cause discontinuity in the provision of safe care⁶⁷ and impede the therapeutic trajectory for a patient. These gaps present major patient safety threats and can impact the quality of care delivered.

Shift-to-Shift Handoff

There are paradoxes in communication and handoffs, especially at shift changes.²⁰ Many human factors play a role. Human factors (ergonomics) focus on behavior and interaction between human beings and their environment. Human factors engineering focuses on “how humans interact with the world around them and the application of that knowledge to the design of systems that are safe, efficient, and comfortable”⁷⁶ (p. 3). The handoff poses numerous human factors engineering implications. From the perspective of patient safety, the primary purpose of the shift report or shift handoff is to convey essential patient care information,^{14, 43, 55, 78, 79} promote continuity of care^{13, 41, 77, 78, 80} to meet therapeutic goals, and assure the safe transfer of care of the patient to a qualified and competent nurse. However, other reported purposes of shift report include education,^{41, 78, 81} debriefing,^{14, 41} socialization,^{78, 82} planning and organization,⁷⁸ enhancement of teamwork,⁸¹ and supportive functions.⁸³

The intershift handoff is influenced by various factors, including the organizational culture. An organization that promotes open communication and allows all levels of personnel to ask questions and express concerns in a nonhierarchical fashion is congruent with an environment that promotes a culture of safety.⁵⁸ Interestingly, one study reported novice nurses seeking information approached those seen as “less authoritarian.”⁸⁴ The importance of facilitating communication is critical in promoting patient safety. The shift-to-shift handoff is a multifaceted activity.^{78, 85, 86} A poor shift report may contribute to an adverse outcome for a patient.⁵⁵

Handoff intricacies

A phenomenon well known to nurses is the use of nurse-developed notations, “cheat sheets” or “scraps” of information, while receiving or giving intershift reports. A study of such note taking found scraps are used for a variety of purposes, including creating to-do lists and recording specific information and perceptions about the patient and family.⁸⁷ This approach presents some challenges, as no one else has easy access to the information; therefore, continuity of care may be compromised during a meal break, for example, or if the scrap or cheat sheet is misplaced.

Method of shift-to-shift handoff

Handoffs are given using various methods:^{13, 41, 88, 89} verbally,^{75, 77} with handwritten notes,^{80, 87} at the bedside,^{41, 52, 56, 57, 90, 92} by telephone,⁹¹ by audiotape,^{41, 53} nonverbally,⁵⁴ using electronic reports,⁹² computers printouts,¹⁴ and memory.¹⁴ The strength of the bedside report method is its effort to focus on and include the patient in the report. There have been concerns regarding patient confidentiality,^{41, 52, 56, 90} which could be compromised if not carefully addressed. A qualitative study focused on describing the perceptions of patients who were present during a bedside report found some patients are in favor of bedside handoff, while others are not.⁵² Patients also expressed concern regarding the jargon used by nurses.⁵² One patient noted that including the patient in the handoff added another level of safety as erroneous data could be addressed and corrected.⁵² Case studies indicate the bedside handoff may be implemented for a number of reasons, including addressing specific issues and improving care delivery.^{57, 92} A summary of the strengths and weaknesses of verbal, bedside, written, and taped shift-to-shift reports is included in Table 3.

Table 3

Nurse-to-Nurse Change-of-Shift Handoff Report

The challenge during handoffs across settings and times is to identify methods and implement strategies that protect against information decay and funneling,⁶⁶ contributing to the loss of important clinical information. It is a challenge to develop a handoff process that is efficient and comprehensive, as case studies illustrate.^{57, 88, 92, 93} Observation of shift handoffs reveals that 84.6 percent of information presented in handoffs could be documented in the medical record.⁴² A concern that emerged in this study was some handoff reports actually “promote confusion,” and therefore the authors advocated improving the handoff process.⁴²

Another concern with handoffs is the degree to which the report is actually congruent with the patient’s condition. One study found 70 percent congruence between the shift report and the patient’s actual condition, with an omission rate of 12 percent.²² A synthesized case example of a psychiatric patient presents the adverse consequences for the patient if essential information is not communicated.⁹⁴ The importance of communicating objective descriptions of the patient condition is highlighted.

A study focusing on assessing the effects of manipulating information in a shift handoff on the receiving nurse’s care planning found in the different types of taped reports that the information recalled ranged from 20 percent to 34 percent.⁹⁵ Another study, by Pothier and colleagues,⁵⁵ examined different methods for transferring information during 5 consecutive simulated handoffs of 12 fictional patients. Three methods of handoffs were analyzed; the method demonstrating the greatest amount of information retention involved utilization of a preprinted sheet containing patient information with verbal report, followed by note taking and verbal report method, and lastly, only verbal report. The retained total data points for each style of handoff varied considerably during the five handoffs. Over 96 percent to 100 percent of information was retained using the preprinted sheet containing patient information and verbal report. Only 31 percent to 58 percent of the data were retained using the note taking style and verbal report.⁵⁵ The verbal-only style demonstrated the greatest amount of information loss, with retention ranging from 0 percent to 26 percent.⁵⁵ None of the data was retained using the verbal-only method for two handoff cycles. The insertion of incorrect information was observed in the verbal-only method. The generation of incorrect data did not occur at all during the handoff with the written or preprinted form style of report. This study⁵⁵ supports the use of a consistent preprinted form with relevant patient information during shift report, with less reliance on verbal-only reports, in order to optimize communication.

Evidence-Based Practice Implications—Handoffs for Today’s Health Care Environment

The Australian Council for Safety and Quality in Health Care evaluated 777 papers for possible inclusion in a literature review on handoffs.¹ A total of 27 papers met the inclusion criteria, but it was reported that “no best practice” (p. 2) existed related to systems emerged in the search—although a number of recommendations were provided for systems, organizational, and individual factors.¹ Handoffs are an extremely complex phenomenon to study as they occur in a variety of settings; stages along the continuum of care; and among various personnel with different skill sets, priorities, and educational levels.

Contributors to handoff problems included failed communication,^{4, 5, 6, 7, 10, 31} omissions,^{31, 64, 108} distractions,¹⁰⁸ lack of or illegible documentation,^{31, 33, 73} lack of utilization of transfer forms,⁶⁹ incomplete medical records,⁶⁴ lack of medication reconciliation,^{129, 130} and lack of easy accessibility to information.^{6, 33, 73} A variety of environmental issues emerged—including designs^{28, 58}—that served to increase, rather than decrease, the number of handoffs. Interfacility handoffs posed a number of challenges, including cultural differences⁷³ and lack of integrated systems, thereby increasing the likelihood of transmission difficulties between organizations. Organizational and system failures or lack of systems to support the handoff process emerged as contributors to adverse events.^{4, 6, 7, 10} A lack of knowledge was found regarding effective handoff processes,¹¹⁷ and education on effective handoff strategies was also lacking.^{3, 117} Handoff processes need to include consideration of the person involved in the handoff and their level of education, expertise, and comprehension (e.g., the novice nurse’s informational needs may be different from the expert nurse).⁴¹ Novices also differ from expert nurses in their use of information.⁸⁴

There must be an organizational commitment to the development and implementation of systems that support effective handoffs as well as a just culture.^{133, 134} This includes cultures of safety and learning.¹³⁴ A safety culture supports identifications of problems and errors to be addressed to prevent the recurrence.^134–136 A culture of learning promotes learning from the experiences of the past to prevent a recurrence of tragic fumbled handoffs. Environments and processes need to be designed to promote desired outcomes⁷⁶ and enhance patient safety.¹³⁷

Effective Handoff Process

A recurrent theme observed in the handoff literature is the need to convey essential information to the oncoming shift or provider. A standardized process to guide the transfer of critical information has been recommended.^{33, 34, 45, 48, 108} The use of protocols that include the use of phonetic and numeric clarifications are important in helping convey information accurately.^{11, 136} The Sentara health care organization adopted behavior-based expectations to improve the handoff process and used tools including the five Ps (patient/project, plan, purpose, problems, and precautions).¹³⁶ It reported a 21-percent increase in effective handoffs.¹⁴² A medical center using SBAR in the handoff process reported less missing information in handoffs after implementation of SBAR.⁴⁵ The use of protocols such as safe practice recommendations related to reconciling medications^{131, 132} and communicating critical test results^{49, 50} should be used in designing strategies for more effective handoffs. Some hospitals have reported developing strategies to improve the communication between the hospital and other providers.^{44, 71, 73, 74, 114} A summary of problems and barriers with handoffs observed in this review of literature are presented in Tables 4, 5, and 6. Strategies that have been reported in the literature are also included in the tables; however, more research is needed to identify evidence-based guidelines. The Evidence Table at the end of this chapter presents a summary of selected sources addressing handoffs.

Table 4

Factors, Problems, and Strategies Cited in the Literature

Table 5

Issues, Problems, and Strategies Cited in the Literature

Table 6

Issues, Problems, and Strategies Cited in the Literature

Evidence Table

Selected Sources on Handoffs—Nursing Handoffs, Quality Improvement Activities, Interdisciplinary Handoffs

Research Implications

Following are suggested questions for future research:

• What are the best systems designs to reduce unnecessary handoffs? How can they best be implemented?
• What are best strategies for handoffs in various settings (i.e., nurse to nurse, unit to unit, agency to agency, physician to nurse)?
• What are the most effective strategies, instruments, and tools to employ to assure maximum transfer of and receipt of accurate, relevant, up-to-date information?
• How can electronic technology best be deployed to support and enhance effective handoffs, decrease errors, and improve patient safety and patient outcomes?
• What are the best techniques for assuring critical information is forwarded and not omitted or overlooked when received?
• How can handoff contributors to medication errors be addressed and decreased?
• What are the critical data elements that should be transferred by type of service, specialty, profession, and setting?

Basic to the provision of quality health care is the ability to communicate with one another and safely handoff patient care in a seamless manner so every patient can benefit from each phase of care through a well-executed handoff. This is a process that is ubiquitous but also a high-risk endeavor in many settings. More research is needed in this critical patient safety arena to promote interdisciplinary approaches to patient safety throughout the continuum of care.

Acknowledgments

Acknowledgment

The authors wish to acknowledge Stephanie Narva Dennis, M.L.S., for support and assistance in conducting the literature search.

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