PSNet primers are regularly reviewed and updated by the PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field.

Background

A handoff is the process of one healthcare provider updating another of the status of one or more patients for the purpose of handing over responsibility for their care. This can include a physician updating another at the change of shift, a nurse transitioning a patient from one department to another, or emergency medical services handing off a patient to the emergency department.

This Primer will discuss handoffs in the context of transfers of care during hospitalization. For information about safety issues at the time of hospital discharge, please see the related Patient Safety Primers Adverse Events after Hospital Discharge and Post-Acute Transitional Services: Safety in Home-Based Care Programs.

Handoffs have been linked to adverse clinical events in settings ranging from the emergency department to the intensive care unit. One study found that being cared for by a covering resident was a risk factor for preventable adverse events; more recently, communication failures between providers have been found to be a leading cause of preventable error in studies of closed malpractice claims affecting emergency physicians and trainees. The seemingly straightforward act of communicating an accurate medication list is a well-recognized source of error. To avert this problem, hospitals are required to "reconcile" medications across the continuum of care. (For more information, see the related Primer "Medication Reconciliation.")

Implementing Effective Handoff Protocols

Guidelines for safe handoffs focus on standardizing the process. Efforts to improve the quality of clinical handoffs must enhance the quality of both written and verbal communication. In addition to accurate and complete written information, effective handoffs require an environment free of interruptions and distractions, allowing for the clinician receiving the handoff to listen actively and engage in a discussion when necessary. 

The seminal I-PASS study demonstrated that in a teaching hospital setting, implementation of a standardized handoff bundle—which included a mnemonic for standardized oral and written information, training in handoff communication, faculty development, and efforts to ensure sustainability—markedly reduced the incidence of preventable adverse events associated with handoffs. The I-PASS mnemonic stands for:

• 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 signout
• 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

The I-PASS signout format is considered the gold standard for effective signout communication between physicians and has also been shown to improve the quality of nursing handoffs. The I-PASS handoff tool has been effective in cancer care and pediatric emergency care. It has also been adapted to include patients and families. 

Another structured handoff tool is Situation, Background, Assessment, Recommendation (SBAR). 

1. Situation: What is happening at the moment? (Describe the current issue or concern.)
2. Background: What is the context? (Provide relevant patient history, background, or any pertinent information.)
3. Assessment: What do you think the problem is? (State your analysis or interpretation of the situation.)
4. Recommendation: What would you suggest or recommend? (Propose the next steps or actions needed.)

SBAR helps ensure that communication between healthcare professionals is organized, minimizing misunderstandings and improving patient safety. Results are mixed on the effectiveness of SBAR in improving transfer of information. A systematic review found that when it was bundled with other safety interventions, patient outcomes improved. 

Hospitals may also develop and implement bespoke handoff tools. The University of Pennsylvania developed a handoff tool in the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study to improve communication between operating room and intensive care unit providers. A simulation study in the United Kingdom tested the Traffic Light communication tool with operating room staff. Traffic light yielded more accurate information transfer, took less time to use, and was preferred by the majority of study participants compared to SBAR. Researchers are also considering how artificial intelligence could support patient handoffs.

Current Context

In 2006, the Joint Commission established a National Patient Safety Goal that addressed handoffs and four years later established it as a Provision of Care standard (PC.02.02.01). The standard that requires “the organization's process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient.” A Sentinel Event Alert was issued in 2017 to improve the quality of hand off communication. The Joint Commission does not recommend a specific handoff tool, but states the communication should include content such as illness assessment, patient summary, to-do action list, and contingency plans, and be delivered face-to-face whenever possible. 

The Accreditation Council for Graduate Medical Education also requires that residency programs maintain formal educational programs in handoffs and care transitions.