Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a single patient1 to broader communication issues between physicians and nurses.2 In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases.3–5 The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009.6 Communication problems have long been noted as a major contributing factor to these sentinel events. Sutcliffe et al7 conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.
Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures8 and have been called “remarkably haphazard.”9 As defined by the Joint Commission, handoff communication refers to a standardized process “in which information about patient/client/resident care is communicated in a consistent manner.”10
Retrospective reviews of malpractice claims in the ambulatory setting11 and emergency department12 showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.13 A review of 146 surgical errors found that 41 (28%) involved handoffs.14 Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the reason for the mistake was a problem with handoffs.15
Numerous surveys document health care staff concern. In an Agency for Healthcare Research and Quality 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that “important patient care information is often lost during shift changes.”16 When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.17
Reduced resident duty hours were first introduced in New York State in 1989 and were mandated for all U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many have expressed concern about the resultant need for increased handoffs and reduced continuity of patient care.18 As a result of reduced hours, patients can be seen by three different physicians in the first 24 hours of their care.19 Seventy-six percent of 29 surgical residents in a New York study agreed that continuity of care had been negatively affected as a result of duty hours changes.20
Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been found to lead to increased in-hospital complications,21 preventable adverse events,22 increased cost due to unnecessary tests being ordered by residents not familiar with the patient,19 and diagnostic test delays.21 In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.22
Night float systems, often implemented to ensure that residents do not exceed duty hours limits, have been noted to result in inadequate information transfer to the covering residents.23 Nurses have expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a new resident night float system agreed that “residents don’t know the patients as well as in the old system.”24
Other issues surrounding attending physicians’ and residents’ handoffs have been documented. Gandhi25 notes that inadequate handoffs can lead to diffused responsibility, which can be a major contributor to medical errors. In addition, Coiera26 found that health care communications are prone to interruptions, with a third of communication events (30.6%) interrupted.27 Many of these interruptions result in inefficiencies,28 and interruptions during handoffs are likely to lead to failures of working memory,29 which result in decreased recall accuracy.
In 2006, the average length of stay for all hospitalized patients was 4.8 days.30 Assuming that patient care transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the average patient will be handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.
In response to concerns about inadequate health care handoffs, a number of national patient safety organizations have highlighted the importance of communication, including the Institute for Healthcare Communication31 and the National Quality Forum. In 2006, the Joint Commission created a new National Patient Safety Goal on handoffs.32 In 2009, the goal remains virtually unchanged, requiring the organization to implement “a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.”33
As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of poor communication and inadequate handoffs in health care. The purpose of the current study was to identify all English-language articles on resident and/or attending physicians’ handoffs in the United States, conduct a systematic review of research studies, perform a qualitative review of barriers and strategies mentioned across all articles, and identify features of structured handoffs that have been shown to be effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient Care Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.
National initiative work group
A work group of the National Initiative developed resources and wrote systematic reviews of the literature in support of the National Initiative's goals. We performed this study as one of a series of literature reviews initiated by that group. The methodology that we employed included regular, substantive discussions about manuscript concept and design, such as key questions, inclusion and exclusion criteria, and search strategies. There were critical interchanges among us about all important aspects of each systematic review written by this group, including those for this report, and we reached consensus on how to treat each systematic review. The specific subject, appropriate technique, and final presentation of this systematic review are the product of a progressive, iterative, and qualitative process of refinement.
We conducted a thorough and systematic literature search of English-language articles published on handoffs from 1987 to June 4, 2008 using Ovid Medline, Medline In-Process & Other Non-Indexed Citations, CINAHL, HealthSTAR, and Christiana Care Full Text [email protected], followed by reference section review. The search terms used were hand-off$, handoff$, signout$, sign out$, sign-out$, handover$, hand-over$, signover$, and sign-over$. A total of 2,590 articles were identified. All titles were reviewed for possible inclusion, and 401 articles were obtained for further review (Figure 1). Reference sections of all 401 articles were reviewed for additional articles.
Articles meeting the following criteria were eligible for review of barriers and strategies: English language, indexed in PubMed, published between 1987 and June 4, 2008, focused on health care handoffs in the United States, and including information about either resident or attending physicians’ handoffs. Articles included in the systematic review had one of the following study designs: randomized controlled trial; nonrandomized trial, with control or comparison group; single-group pre- and posttest, cohort study; single-group cross-sectional research; single-group posttest only, or qualitative research.
Trained reviewers (J.L. and L.R.) deemed that 46 articles met inclusion criteria for the initial review of barriers and strategies. Using an iterative process, an abstraction form was developed to confirm eligibility for full review, assess article characteristics, and extract data relevant to the study questions. This iterative process started with an initial form, which was used by two reviewers (J.L. and L.R.) to independently abstract data from four articles. The reviewers then met to discuss the abstraction form for inclusion of all relevant data. A second, more detailed form was then created for abstraction. Reviewers (J.L. and J.M.) independently abstracted all data. Most abstraction disagreements were minor, and all disagreements were quickly resolved during discussion, when a consensus was reached on the abstracted data.
Quality scoring system
Downs and Black34 created a valid and reliable checklist designed to assess both experimental and observational studies. Two systematic reviews35,36 of published systems (scales and checklists) designed to assess study quality have ranked the scale developed by Downs and Black as one of the best. Both of these systematic reviews went on to suggest that some modifications might be useful, depending on the specific topic and study designs. Therefore, five of us (L.R., J.L., J.M., J.J., J.S.P.) developed a quality scoring form based on this approach, using four of the original items and eight modified items, which yielded scores ranging from 1 to 16, with 16 being the highest possible score (see Chart 1). This quality scoring form contained two items related to study type and sample size, five items related to reporting, and five items related to internal validity.
If a study included multiple assessment formats, such as interviews and a questionnaire, that resulted in different sample sizes, the largest sample was used as the sample size in the quality scoring form. There was no way to determine the number of independent study participants for each assessment method. Thus, to avoid counting the same study participant multiple times, we credited the study with the largest reported sample only.
Quality scores were independently obtained from reviewer pairs (L.R. and J.L. or J.J.) for each study. The interrater reliability was assessed for all identified research studies (n = 18). Overall agreement was 97.7%, and Cohen's kappa for agreement between the two reviewers was r = 0.96, P < .001. All differences were resolved through discussion to yield a final quality score for each study.
Qualitative analysis of barriers and strategies
Conventional content analysis is a type of qualitative research used when there is limited or no existing theory on the phenomenon of interest.37 This analysis involves an iterative process that allows themes to arise from data. Researchers immerse themselves in the content and allow categories to emerge.37
All barriers and strategies mentioned in the reviewed articles were identified and listed in phrase format in two continuous lists, one for strategies and another for barriers. Reviewers (J.L. and L.R.) met to compare lists and, through discussion, agreed on final comprehensive lists. Through an inductive iterative process, category labels were created and all phrases were moved to a category or subcategory. The final lists were reviewed by J.M. for coherence and consistency.
Forty-six articles describing resident and/or attending physicians’ handoffs were identified. Thirty-three (71.7%) were published between 2005 and 2008 (Figure 2). Content analysis yielded 91 barriers in eight major categories and 140 strategies in seven major categories (Table 1).
Twenty-two articles presented anecdotal data,38–58 one of which had a physician handoffs case example and nursing handoffs research59; three provided circumscribed reviews,60–62 and three were editorials.63–65 The remaining 18 articles reported research on handoffs and were analyzed in depth (see the Appendix).66–83 Only one80 research study did not involve residents or have a graduate medical education focus. Quality assessment scores for the research studies ranged from 1 to 13 (possible range 1–16). Six studies obtained scores of 8 or less, eight had scores between 8.5 and 11.5, and four achieved quality scores of 12 to 13.
Only 6 of 18 (33.3%) research studies identified effective handoff features.66,67,69,71,77,78 In studies comparing computerized handoff systems with other methods, such as personal handwritten notes, the computerized or electronic system performed better. Residents were more likely to have all patients on their list,67 to report that they received all important information,78 to have increased satisfaction with the handoff system,67 to spend less time in prerounding and rounding activities,67 and to self-report decreased adverse events related to handoffs.77 Others have noted that resident-maintained lists in a database, such as a Microsoft Word file or Excel database, contain content and medication errors.69,71 However, interns using standardized, self-maintained sign-out cards reported fewer poor sign-outs and were more likely to record code status, patient age, and allergies.66
As stated earlier, we identified 46 articles describing residents’ and attending physicians’ handoffs in the United States. Eighteen were research studies (39.1%), only two of which were randomized controlled trials. The majority (71.7%) of articles were published in recent years, which is not surprising, given the Joint Commission's National Patient Safety Goal on handoffs issued in 2006. However, as demonstrated by our quality assessment scores (see the Appendix), there is a remarkable lack of high-quality outcomes studies. It is notable that one third of the reviewed research studies obtained quality scores at or below 8 (out of a possible 16), and only one study achieved a score of 13.
One purpose of the current study was to identify features of physicians’ handoffs that have been shown to be effective. Unfortunately, only 6 of the 18 (33.3%) research studies included measures of effectiveness. Of the three studies using computerized handoff systems, one was a stand-alone system,78 and the other two had some linkage with the hospital computer system.67,77 While these all provided a structured template, they also relied to varying degrees on residents to enter information, which introduces an opportunity for errors to occur.69,71 Most of the studies assessing effectiveness used self-reported data, with a few exceptions. Van Eaton and colleagues67 looked at the number of patients missed on resident rounds and showed a decrease from 5 to 2.5 patients/team/month (P = .0001) when using a computerized handoff system. Two other studies assessed errors on resident-maintained handoff forms when compared with the medical record69,71 (a surrogate for actual medical errors) and, not surprisingly, found errors on the resident lists.
Of note, two survey studies documented a lack of formal handoffs instruction during residency, with 60% to 74.4% (internal medicine72 and emergency medicine,73 respectively) reporting that they have no lectures or workshops on the topic. Although 72.3% of the 185 emergency medicine residency/fellowship program directors studied agreed that standardized handoffs would reduce medical errors,73 the majority did not have a uniform policy or procedure regarding handoffs. Only one of the studies reviewed here included the development, implementation, and assessment of a formal, structured handoffs curriculum.75 Horwitz and colleagues75 provide a comprehensive curricular template for others to use; however, they relied on postsession evaluations of perceived comfort and importance of handoffs. We commend their plan to conduct observation of handoff skills and look forward to their future publications.
Almost all of the research articles (17 of 18; 94%) were conducted within a residency program. Graduate medical education has taken the lead in conducting handoffs research, which is one demonstration of the value added to health care by medical education.
We identified 91 barriers to effective handoffs that could be organized into eight major categories. Of barrier categories, communication issues were reported most frequently (30.8%), with general communication barriers ranging from not listening to inadequate communication. Because effective communication is an essential component of handoffs, this was an expected finding. However, hierarchy and social barriers constituted a less intuitive group. Here, we found things such as relational communication barriers and residents not being likely to hand off work to more senior residents, because of a rigid reliance on hierarchical norms that prohibit such behavior. Thus, adequately addressing handoff issues will require more than protocols, structure, and training. Understanding the complex social structures and hierarchies in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, will be required.
We identified 140 strategies that could be organized into seven major categories. Strategies for standardization were noted most frequently (44.3%), with technological solutions (16.4%), such as computerized handoff systems, next. Interestingly, whereas communication issues constituted approximately one third of barriers, improving communication skills was noted much less frequently (11.4%) as a strategy. Standardization would address some communication issues, but not all, such as language differences. Providing training or education (10%), evaluating the process (7.1%), and addressing environmental issues (5.7%), such as lighting and limiting interruptions and noise, make intuitive sense. However, a less obvious strategy was insuring the recognition that a transfer of responsibility/accountability (5.0%) had occurred.
Limitations and strengths
Handoffs in a variety of environments were studied, which makes it difficult to use our findings to formulate barriers and strategies for use in every handoff situation. For example, some techniques may be better applied to inpatient medicine as opposed to the emergency department. In addition, we abstracted barriers and strategies from all sections of the articles studied, including the introduction. This may have resulted in overemphasis of some barriers or strategies, depending on the author's views and on repetition. However, we only counted the same barrier or strategy multiple times if the wording was significantly different in subsequent use and if the two instances could stand alone as different aspects of the same category.
Another potential limitation is that the barriers and strategies we identified (Table 1) represent the opinions of the authors of the reviewed studies. Further, we identified the barriers and strategies through a qualitative process. Although they seem intuitively relevant, they were not derived from research studies designed to identify handoff barriers and strategies.
The current study is limited by the Ovid search strategy used. Specifically, the selected search terms may not have included all relevant terms. We strengthened the possibility of identifying all articles that met inclusion criteria by reviewing the reference sections of all obtained articles. Although this strategy minimizes the risk of missing germane studies, it does not eliminate the possibility.
Publication bias refers to the possibility that high-quality studies with negative results may not have been published. Others have noted that many quality improvement (QI) projects are not published.84 In addition, it has been our observation that some QI projects are published in newsletters, with the authors never submitting them to peer-reviewed journals. Thus, there may be outcomes studies of handoffs that are not in the peer-reviewed literature. However, the explicit search strategy, clear inclusion criteria, and systematic process used to identify and evaluate articles strengthen the quality of this review.
Although our quality scoring system was based on a validated methodology developed to assess experimental and observational studies together, our system has not been validated across multiple settings and investigators. The relative weightings may require refinement, and there may prove to be additional relevant categories. The system did have a high internal reliability, and reviewers of various educational backgrounds and experience found it straightforward and easy to use. Further, the quality scoring system provides a reproducible template for the assessment of handoffs articles.
Numerous authors have noted the dearth of research focused on handoffs.45,57,70,83,85,86 In addition, there are risks involved in implementing interventions without evidence supporting their effectiveness.87 Winters and colleagues87(p1,647) noted that “[n]ational efforts to improve patient safety should be supported by sufficiently strong evidence to warrant such a commitment of resources.”
Evidence-based practice is informed by high-quality research. Recent publication guidelines for patient safety and quality initiatives have established a framework for standardized reporting.88,89 We recommend that future handoffs studies use the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines.89 Many of the studies reviewed here would have been improved by doing so.
Others have noted that it may be unreasonable to expect patient safety and quality studies to follow the design rigors of randomized controlled trials.87 However, the RAND/UCLA Appropriateness Method provides a structured, rigorous method to synthesize data from other clinical study types with expert opinion to provide the best available guidelines.90 Unfortunately, the literature on handoffs identified here is not of sufficient quality and quantity to synthesize into evidence-based recommendations.
Although the Joint Commission is calling for structured handoffs, we identified very little evidence to support the use of any specific structure, protocol, or method. However, direct observation of handoffs in other settings (i.e., NASA mission control, nuclear power, railroad, and ambulance dispatch) with high consequences for error, yielded 21 common strategies,91 which could offer a starting point in the development of health care handoffs research. Our review of the U.S. physicians’ handoffs literature has led us to develop a list of research questions, organized by the content domains of knowledge, attitudes, skills, process outcomes, and clinical outcomes (see List 1).
Across the United States, hospitals are implementing structured handoff protocols in an effort to comply with Joint Commission requirements. High-quality outcomes studies that focus on systems factors, human performance, and the effectiveness of protocols and interventions are urgently needed. These studies should address the barriers and strategies identified here. In addition, handoffs in different disciplines are likely to have different requirements and issues. For instance, an emergency department handoff will need to have different content than one for inpatient medicine or pediatrics. Therefore, researchers should conduct discipline-specific handoff studies.
We call for rigorous outcomes studies designed to (1) assess the effectiveness of handoffs, (2) determine the elements of handoffs that lead to improved patient outcomes, and (3) identify the best implementation strategies. Finally, these studies should be reported using the SQUIRE guidelines. Without these studies, hospitals across the United States are destined to waste time, resources, and effort on flawed handoff practices.
Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian of the Lewis B. Flinn Medical Library, Christiana Care Health System, for conducting literature searches; Dolores Ann Moran, medical library assistant II, and Janice Evans, medical library assistant II, for their assistance in locating articles; and Donald Riesenberg, MD, for feedback on the manuscript.
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