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Using Simulation to Teach and Study Healthcare Handoffs

Cooper, Jeffrey B. PhD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2010 - Volume 5 - Issue 4 - p 191-192
doi: 10.1097/SIH.0b013e3181eab91c
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In this issue of Simulation in Healthcare, we have two scenarios that aim to reduce harm associated with handoffs between healthcare providers.1,2 Handoffs (also called handovers or shift changes) can been defined as “the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient.”3 They are now recognized as some of the most critical issues in patient safety. There is a growing body of literature that reveals that handoffs are a causal factor in many adverse events.4,5 Although there are also numerous resources about how to reduce the harm associated with handoffs6 and how they are done in other industries,7 there is not much solid evidence about what really is effective.3 It seems to be common sense to use some form of formal protocol during handoffs.

Numerous such protocols have been suggested; one of the scenarios published in this issue is based on a specific protocol with a mnemonic that is purported to be effective. However, we do not know much about what kinds of protocols and processes work best in healthcare. Nonetheless, using simulation as a training tool to raise awareness and motivate more attention to the risks of handoffs surely is sensible. Simulation should also be used to study how to train effectively. We can do a bit of both at the same time, ie, training and research.

My involvement in handoffs began over 30 years ago, when our team published what may have been the first study of this topic and later a recommendation to conduct a specific protocol for handoffs in anesthesia.8,9 Looking back on those publications, I wish we had the simulation facilities we have now, so that we could have studied this kind of intervention systematically. The idea of a checklist seemed obvious to us. I still think it makes sense. In retrospect, nothing is that simple. I believe that handoffs are the moments of greatest vulnerability in the process of patient care. Thus, I am pleased to see that this topic is finally being addressed so intensely. We are fortunate to now have simulation available as a tool for training. These scenarios should make it a bit easier for more sites to get started on doing simulations on this topic. However, I remain concerned that we do not really know what is the right process to teach or even how to teach it.

The problem these scenarios are addressing is that every time one provider or provider team hands responsibility over to another provider or team there is a risk of losing critical information about the patient and all that surrounds his or her process of care. What we identified in our studies in the1980s is that sometimes a handoff (we were studying one anesthesia professional relieving another during a surgical procedure) could actually be beneficial by virtue of having a new set of senses coming in to assess the situation. Often, the new person discovered a problem that the person he or she was replacing had missed.8

In the current era, and in nonanesthesia settings, there are many more handoffs (at least in teaching hospitals; an unwanted side effect of work-hour limitations), often with responsibility for multiple patients exchanged at one time, and with much more explicit and tacit knowledge to convey at each change of the guard. The studies referred to above and others referenced in these two scenario reports have identified many types of errors and adverse events that result. Other studies have pointed to the ways in which high-risk industries manage their handoffs.6 Most of those handoffs are for shift changes. In healthcare, there are many additional critical handoff events for other reasons, eg, transfers from one place of care to another. Although we can learn a lot from what other industries do, this is one of those instances where healthcare has special issues that may require different kinds of processes. If nothing else, the details of the protocols for handoffs will be specialized. We will need to figure out how to make this process optimally safe and effective for each setting and possibly even for each type of case. Simulation offers a perfect venue for doing that.

Looking at these two scenario descriptions helps us to see that there is more than one way to construct a scenario. One of the reports uses the Team STEPPS “I PASS the BATON” mnemonic. The other does not refer to any written protocol. Which is best? How do we know if the mnemonic works as intended? Do people really remember what the letters mean, especially when there are many items? The review by Riesenberg et al10 of 45 reports of 24 different handoff mnemonics reported only four research studies and all with small sample sizes and without validated instruments. The message is clear: we need a lot more research about healthcare handoffs, about mnemonics, and also research on how to teach handoff processes effectively.

The scenarios involve two very different handoff situations. One is a handoff in the operating room (similar to those we studied 30 years ago); the other is a transfer in the intensive care unit postcardiac surgery. They involve different kinds of providers and different types of cases, although, coincidentally, both are pediatric. The differences in the handoff characteristics illustrate how many different types of issues there are to consider in training for handoffs. Many more such scenarios will be needed to reach all the different types of providers, teams, and locations where handoffs occur. I imagine that we could devote a year of entire journal issues to publishing handoff scenarios (or perhaps start a Journal of Handoff Science and Practice!). I do not think that is going to happen, but perhaps establishing a repository of handoff scenarios somewhere would be helpful. It is not that each simulation program cannot create its own. Rather, a lot of effort goes into working out the details and practicing the scenario to make sure it works.

That leads me to a different issue. How much information is really needed in a published scenario description to make it useful? Is there sufficient detail in either of these scenarios? What should be the objective of a scenario report? Should it be similar to a play that offers enough for directors to interpret any way they wish? Do we just need enough to be prepared to practice the scenario? or Should we require that authors also report some experience in how the scenario works, including, for instance, what types of issues surface in the debriefing? The journal has not yet published enough of these to develop a minimum standard. I prefer to require that no scenario be published without some information about how well it works, including what types of failure modes are likely. If these are to be credible publications, and optimally useful to readers, we should demand some effort in evaluating the scenarios and reporting on how well they appear to work. Rather than just a report of a single case, we have the opportunity in simulation to present the combined learning from several runs of the same type of patient event. Let us take advantage of that.

Simulation is obviously a great tool to study handoffs, both to figure out what works and to figure out how best to teach what works. Funding agencies have been supporting studies of handoffs. The Anesthesia Patient Safety Foundation recently funded two studies that use simulation as a tool for this research.11 We need more such studies because there are many questions to answer. We cannot answer them all by simulation, but the controlled environment and the numbers of training events many centers are now doing should provide ample opportunities. I urge everyone to go at this work vigorously.

In the meantime, because this is a safety issue, we have to make our best attempts at teaching what we think is right using what evidence there is and some intuition. If nothing else, we need to conduct handoff scenarios similar to these to raise awareness about how vulnerable these moments are. I believe that the simple act of treating each handover similar to a sacred moment will go a long way to reducing harm. My impression is that, until recently, handoffs were not treated in this way and that they were seen as no different than any other moment in the care process. At least we can teach people to be more deliberate about each handoff, as the incoming or outgoing, individual, or team. Mindfulness itself will go a long way toward reducing harm from healthcare's most dangerous moments.


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3. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care April 8, 2010 [Epub ahead of print].
4. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 2008;34:563–570.
5. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866–872.
6. Joint Commission Resources. Handoff Communication: Toolkit for Implementing the NPSG2008; 2008. Available at: Accessed May 25, 2010.
7. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16:125–132.
8. Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 1982;56:456–461.
9. Cooper JB. Do short breaks increase or decrease anesthetic risk? J Clin Anesth 1989;1:228–231.
10. Riesenberg LA, J Leitzsch, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual 2009;24:196–204.
11. Brull SJ. Grant program funds five awards. Anesthesia Patient Safety Foundation Newsletter 2006; 21:69–71. Available at Accessed June 15, 2010.
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