The published literature on handoffs in hospitals: Deficiencies identified in an extensive review

Quality and Safety in Health Care

Volumn 19, Issue 6, 2010, Pages 493-497

  Cohen, Michael D ^a   Hilligoss, P Brian ^a  

^a UNIVERSITY OF MICHIGAN   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE QUALITY; HOSPITAL; HUMAN; PATIENT CARE; REVIEW; STANDARD;

CONTINUITY OF PATIENT CARE; HOSPITALS; HUMANS; QUALITY OF HEALTH CARE;

EID: 78650387914     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2009.033480     Document Type: Article

References (90)

1. Australian Medical Association, Safe handover: Safe patients. 2006.
2. British Medical Association, National Patient Safety Agency, NHS Modernisation Agency. Safe handover: Safe patients 2005.
3. World Health Organization, Joint Commission, Communication during patient handovers. Patient Saf Sol 2007;1:1-4.
4. The Joint Commission, About us: A journey through the history of the joint commission. 2008. http://www.jointcommission.org/AboutUs/ joint-commission-history.htm (accessed 16 Jan 2009).
5. Carroll K, Iedema R, Kerridge R. Reshaping ICU ward round practices using video-reflexive ethnography. Qual Health Res 2008;18:380-90.
6. Broekhuis M, Veldkamp C. The usefulness and feasibility of a reflexivity method to improve clinical handover. J Eval Clin Pract 2007;13:109-15.
7. Maseide P. Medical talk and moral order: Social interaction and collaborative clinical work. Text 2003;23:369-403.
8. AORN. Perioperative patient 'hand-off' tool kit. http://www.aorn.org/ PracticeResources/ToolKits/PatientHandOffToolKit/ (accessed 3 Sep 2008).
9. Loh E. A national survey of medical morning handover report in Australian hospitals. Med J Aust 2007;187:595-6.
10. Solet DJ, Norvell JM, Rutan GH, et al. Lost in Translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005;80:1094-99.
11. Perry S. Transitions in care: Studying safety in emergency department signovers. Focus Patient Saf 2004;7:1-3.
12. Horwitz L, Krumholz HM, Green ML, et al. Transfers of patient care between house staff on internal medicine wards. Arch Intern Med 2006;166:1173-7.
13. Runy LA. Patient handoffs. Hosp Health Netw 2008;82:7.
14. University HealthSystem Consortium. UHC Best Practice Recommendation: Patient Hand Off Communication 2006.
15. Pillow M, ed. Improving hand-off communication Oakbrook Terrace (IL): Joint Commission Resources, 2007.
16. Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: A qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med 2009;53:701-10.
17. Joint Commission. FAQs for the 2008 national patient safety goals. 2008. http:// www.jointcommission.org/NR/rdonlyres/13234515-DD9A-4635-A718- D5E84A98AF13/0/2008-FAQs-NPSG-02.pdf (accessed 27 Aug).
18. Moore C, McGinn T, Halm E. Tying up loose ends: Discharging patients with unresolved medical issues. Arch Intern Med 2007;167:1305-11.
19. Joint Commission. 2008 National patient safety goals handbook. 2008.
20. Shaw G. Handoff Rx: Knowing what to say and how to say it. ACP Observer 2006.
21. Behara R, Wears R, Perry S, et al. A conceptual framework for studying the safety of transitions in emergency care. Adv Patient Saf 2005;2:2309-21.
22. Patterson ES. Structuring flexibility: The potential good, bad and ugly in standardisation of handovers. Qual Saf Health Care 2008;17:4-5.
23. Horwitz LI, Parwani V, Shah NR, et al. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med 2009;54:368-78.
24. Arora V, Johnson J. A model for building a standardsed hand-off protocol. Jt Comm J Qual Patient Saf 2006;32:646-55.
25. Yates GR, Bernd DL, Sayles SM, et al. Building and sustaining a systemwide culture of safety. Jt Comm J Qual Patient Saf 2005;31:684-9.
26. Horwitz L, Moin T, Green M. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007;22:1470-4.
27. Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competencybased approach to improving handoffs. Qual Saf Health Care 2008;17:11-14.
28. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32:167-75.
29. Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13:(Suppl 1):i85-90.
30. Sibbald RG, Ayello EA. From the experts. SBAR for wound care communication: 20-second enablers for practice. Adv Skin Wound Care 2007;20:135-6.
31. ED Management. ED accreditation update. SBAR techniques help EDs comply with handoff regs. ED Manag 2007;19:suppl 3-4.
32. Brown V. Shift report redesign. Health Manag Technol 2007;28:18-19.
33. Landro L. The informed patient: Hospitals combat errors at the 'hand-off'; new procedures aim to reduce miscues as nurses and doctors transfer patients to next shift. Wall St J 2006:D1.
34. Schneider D. SBAR initiative to improve staff communication. Healthcare Benchmarks Qual Improv 2005;12:40-1.
35. Grbach W, Vincent L, Struth D. Reformulating SBAR to 'I-SBAR-R.' 2007. http://qsen. org/teachingstrategies/reformulating-sbar-to-i-sbar-r/view (accessed 18 Jul 2008).
36. Monroe M. SBAR: A structured human factors communication technique. Health Beat 2006;5:13-24.
37. McFerran S, Nunes J, Pucci D, et al. Perinatal patient safety project: A multicenter approach to improve performance reliability at Kaiser Permanente. J Perinat Neonatal Nurs 2005;19:37-45.
38. Baldwin L, McGinnis C. A computer-generated shift report. Nurs Manag (Harrow) 1994;25:61-4.
39. Petersen L, Brennan T, O'Neil A, et al. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.
40. Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005;200:538-45.
41. Vidyarthi A, Arora V, Schnipper J, et al. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-66.
42. Van Eaton EG, Horvath KD, Lober WB, et al. Organizing the transfer of patient care information: The development of a computerized resident sign-out system. Surgery 2004;136:5-13.
43. Adamski P. Implement a handoff communications approach. Nurs Manag (Harrow) 2007;38:10-12.
44. White RS, Hall DM. The Bermuda triangle healthcare. An illinois healthcare system closes the gaps in patient handoff communication. Health Manag Technol 2008;29:30-1.
45. Porteous JM. iSoBARda concept and handover checklist: The National Clinical Handover Initiative. Med J Aust 2009;190:S152.
46. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;204:533-40.
47. Johnson LJ. Malpractice consult. Med Econ 2000;77:89.
48. Singh H, Thomas E, Petersen L, et al. Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Arch Intern Med 2007;167:2030-6.
49. O'Connell B, Penney W. Challenging the handover. Collegian 2001;8:14-18.
50. Fassett M, Hannan T, Robertson I, et al. A national survey of medical morning handover report in Australian hospitals. Med J Aust 2007;187:164-5.
51. Bernau S, Aldington S, Robinson G, et al. From medical doctor to junior doctor: The medical handoverda good habit to cultivate student. BMJ 2006;14:188-9.
52. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manag 1999;7:29-36.
53. Fassett RG, Bollipo SJ. Morning report: An Australian experience. Med J Aust 2006;184:159-61.
54. Wolf Z. Learning the professional jargon of nursing during change of shift report. Holist Nurs Pract 1989;4:78-83.
55. Stiles BM, Reece TB, Hedrick TL, et al. General surgery morning report: A competency-based conference that enhances patient care and resident education. Curr Surg 2006;63:385-90.
56. Harvey CM, Schuster RJ, Durso FT, et al. Human factors of transition of care. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety Mahwah (NJ): Lawrence Erlbaum Associates, 2007:233-48.
57. Wolf Z. Nursing rituals. Can J Nurs Res 1988;20:59-69.
58. Kerr MP. A qualitative study of shift handover practice and function from a sociotechnical perspective. J Adv Nurs 2002;37:125-34.
59. Strange F. Handover: An ethnographic study of ritual in nursing practice. Intensive Crit Care Nurs 1996;12:106-12.
60. Mitchell M. Inter-shift reports: To tape or not to tape. Superv Nurse 1976;7:38.
61. Evans AM, Pereira DA, Parker JM. Discourses of anxiety in nursing practice: A psychoanalytic case study of the change-of-shift handover ritual. Nurs Inq 2008;15:40-8.
62. Yonge O. Shift report: A ritual play on a residential adolescent psychiatric unit. J Psychiatr Ment Health Nurs 2008;15:45-51.
63. Stordeur S, D'Hoore W. Organizational configuration of hospitals succeeding in attracting and retaining nurses. J Adv Nurs 2007;57:45-58.
64. Patterson ES. Dangerous shift: Commentary. 2008. http://www.webmm.ahrq. gov/ case.aspx?caseID=188 (accessed 12 Jan 2009).
65. Auerbach A, Landefeld C, Shojania K. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007;357:608-13.
66. Petersen L, Brennan T, O'Neil A, et al. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72.
67. Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008;168:1755-60.
68. Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Qual Saf Health Care 2005;14:401-7.
69. Arora V, Kao J, Lovinger D, et al. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med 2007;22:1751-5.
70. Brown SG, Paine LA, Petty BG. Self-Reported Handoff Event Analysis: Efforts Towards Standardisation of the Handoff Process (Abstract). Society of General Internal Medicine, 30th Annual Meeting Toronto, Ontario, Canada. 2007:136.
71. Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology 2007;68:550-5.
72. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg 2009;197:678-85.
73. Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Med Care 2007;45:997-1002.
74. Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 2007;205:778-84.
75. Berwick DM. The science of improvement. JAMA 2008;299:1182-4.
76. Gawande A. The checklist. (intensive care units and Peter Pronovost's medical care checklist). New Yorker 2007;83:86.
77. Gawande A. On washing hands. N Engl J Med 2004;350:1283-6.
78. Anderson CD, Mangino RR. Nurse shift report: Who says you can't talk in front of the patient? Nurs Adm Q 2006;30:112-22.
79. Harris KT, Treanor CM, Salisbury ML. Improving patient safety with team coordination: Challenges and strategies of implementation. J Obstet Gynecol Neonatal Nurs 2006;35:557-66.
80. Wayne JD, Tyagi R, Reinhardt G, et al. Simple standardsed patient handoff system that increases accuracy and completeness. J Surg Educ 2008;65:476-85.
81. Keenan G, Yakel E, Marriott D. HANDS: A revitalized technology supported care planning method to improve nursing handoffs. 9th International Congress on Nursing Informatics, Seoul, South Korea 2006:1-6.
82. Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf 2006;32:32-6.
83. Ferran NA, Metcalfe AJ. Comment on: Audit of handover practice. Ann R Coll Surg Engl 2008;90:350.
84. Velji K, Baker GR, Fancott C, et al. Effectiveness of an adapted sbar communication tool for a rehabilitation setting. Healthc Q 2008;11:72-9.
85. Catchpole K, Leval MRD, McEwan A, et al. Patient handover from surgery to intensive care: Using formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007;17:470-8.
86. Stetson P, Johnson S, Scotch M, et al. The sublanguage of cross-coverage. Proc AMIA Symp 2002:742-6.
87. Webster J. Practitioner-centered research: An evaluation of the implementation of the bedside hand-over. J Adv Nurs 1999;30:1375-82.
88. Lee LH, Levine JA, Schultz HJ. Utility of a standardsed sign-out card for new medical interns. J Gen Intern Med 1996;11:753-5.
89. Ram R, Block B. Signing out patients for off-hours coverage: Comparison of manual and computer-aided methods. Proc Annu Symp Comput Appl Med Care 1992:114-18.
90. Reiley P, Stengrevics S. Change of shift report: Put it in writing! Nurs Manag (Harrow) 1989;20:54-6.