Handoffs and Transitions of Care

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, Second Edition

Volumn , Issue , 2016, Pages 163-171

  Wears, Robert L ^a,b   Perry, Shawna J ^c   Patterson, Emily S ^d  

^a UNIVERSITY OF FLORIDA HEALTH SCIENCE CENTER   (United States)

^b IMPERIAL COLLEGE LONDON   (United Kingdom)

^c VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE   (United States)

^d THE OHIO STATE UNIVERSITY COLLEGE OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 85136385206     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.1201/b11219-18     Document Type: Chapter

References (53)

1. Akman, O., Gamage, J., Jannot, J., Juliano, S., Thurman, A., and Whitman, D. (2007). A simple test for detection of length-biased sampling. Journal of Biostatistics, 1(2), 189-195.
2. Apker, J., Mallak, L. A., Applegate, E. B., Gibson, S. C., Ham, J. J., Johnson, N. A. et al. (2010). Exploring emergency physician-hospitalist handoff interactions: Development of the handoff communication assessment. Annals of Emergency Medicine, 55(2), 161-170.
3. Apker, J., Mallak, L. A., and Gibson, S. C. (2007). Communicating in the “Gray Zone”: Perceptions about emergency physician hospitalist handoffs and patient safety. Academic Emergency Medicine, 14(10), 884-894. doi: 10.1197/j.aem.2007.06.037
4. Ashby, W. R. (1957). Requisite variety. An Introduction to Cybernetics (pp. 202-218). London, U.K.: Chapman and Hall Ltd.
5. Ashby, W. R. (1958). Requisite variety and its implications for the control of complex systems. Cybernetica, 1, 83-99.
6. Behara, R., Wears, R. L., Perry, S. J., Eisenberg, E., Murphy, A. G., Vanderhoef, M. et al. (2005). Conceptual framework for the safety of handovers. In K. Henriksen (Ed.), Advances in Patient Safety (Vol. 2, pp. 309-321). Rockville, MD: Agency for Healthcare Research and Quality/Department of Defense.
7. Brandwijk, M., Nemeth, C., O’Connor, M., Kahana, M., and Cook, R. I. (January 27, 2003). Distributing cognition: ICU handoffs conform to Grice’s maxims, Retrieved January 27, 2003, from http://www.ctlab.org/properties/pdf%20files/SCCM%20Poster%201.27.03.pdf
8. Caplan, R. A., Posner, K. L., and Cheney, F. W. (1991). Effect of outcome on physician judgments of appropriateness of care. JAMA, 265(15), 1957-1960.
9. Cheung, D. S., Kelly, J. J., Beach, C., Berkeley, R. P., Bitterman, R. A., Broida, R. I. et al. (2010). Improving handoffs in the emergency department. Annals of Emergency Medicine, 55(2), 171-180. doi: S0196-0644(09)01261-X [pii] 10.1016/j.annemergmed.2009.07.016
10. Cohen, M. D., and Hilligoss, P. B. (January 2009). Handoffs in hospitals: A review of the literature on information exchange while transferring patient responsibility or control, Retrieved June 12, 2009, from http://deepblue.lib.umich.edu/handle/2027.42/61522
11. Cohen, M. D. and Hilligoss, P. B. (2010). The published literature on handoffs in hospitals: Deficiencies identified in an extensive review. Quality and Safety in Health Care, 19(6), 493-497. doi: 10.1136/qshc.2009.033480
12. Cooper, J. B. (1989). Do short breaks increase or decrease anesthetic risk? Journal of Clinical Anesthesia, 1(3), 228-231.
13. Cooper, J. B., Long, C. D., Newbower, R. S., and Philip, J. H. (1982). Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology, 56(6), 456-461.
14. Durso, F. T., Crutchfield, J. M., and Harvey, C. M. (2007). The cooperative shift change: An illustration using air traffic control. Theoretical Issues in Ergonomics Science, 8(3), 213-232.
15. Eisenberg, E. M., Murphy, A. G., Sutcliffe, K., Wear, R., Schenkel, S., Perry, S. J. et al. (2005). Communication in emergency medicine: Implications for patient safety. Communication Monographs, 72(4), 390-413.
16. Feldman, J. (2003). Medical errors and emergency medicine: Will the difficult questions be asked, and answered? Academic Emergency Medicine, 10(8), 910-911.
17. Fischhoff, B. (2003). Hindsight ≠ foresight: The effect of outcome knowledge on judgment under uncertainty. Quality and Safety in Health Care, 12(4), 304-311.
18. Gandhi, T. K. (2005). Fumbled handoffs: One dropped ball after another. Annals of Internal Medicine, 142(5), 352-358.
19. Grusenmeyer, C. (1995). Shared functional representation in cooperative tasks: The example of shift changeover. International Journal of Human Factors in Manufacturing, 5, 163-176.
20. Haig, K. M., Sutton, S., and Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175.
21. Henriksen, K., and Kaplan, H. (2003). Hindsight bias, outcome knowledge and adaptive learning. Quality and Safety in Health Care, 12(Suppl 2), ii46-ii50.
22. Hilligoss, P. B., and Cohen, M. D. (2010). What is the goal of patient handoff? Implications for the improvement of care transitions. Paper presented at the Computer-Supported Cooperative Work: Handoffs Workshop, Savannah, GA.
23. Horwitz, L. I., Meredith, T., Schuur, J. D., Shah, N. R., Kulkarni, R. G., and Jenq, G. Y. (2009a). Dropping the baton: A qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of Emergency Medicine, 53(6), 701-714.
24. Horwitz, L., Moin, T., and Green, M. (2007). Development and implementation of an oral sign-out skills curriculum. Journal of General Internal Medicine, 22(10), 1470-1474.
25. Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L., and Bradley, E. H. (2008). Consequences of inadequate sign-out for patient care. Archives of Internal Medicine, 168(16), 1755-1760. doi: 10.1001/archinte.168.16.1755
26. Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L., and Bradley, E. H. (2009b). What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Quality and Safety in Health Care, 18(4), 248-255. doi: 10.1136/qshc.2008.028654
27. Horwitz, L. I., Parwani, V., Shah, N. R., Schuur, J. D., Meredith, T., Jenq, G. Y. et al. (2009c). Implementation and evaluation of an asynchronous physician sign-out for emergency department admissions. Annals of Emergency Medicine, 54(3), 368-378.
28. JCAHO. (2002). Delays in treatment. JCAHO Sentinel Event Alert, (26). Retrieved from http://www.jointcommission.org/sentinel_event_alert_issue_26_delays_in_treatment/(accessed March 18, 2006).
29. Joint Commission on Accreditation of Healthcare Organizations. (2006). 2006 National Patient Safety Goals, Retrieved March 18, 2006, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_hap_cah_npsgs.htm
30. Kitch, B. T., Cooper, J. B., Zapol, W. M., Marder, J. E., Karson, A., Hutter, M. et al. (2008). Handoffs causing patient harm: A survey of medical and surgical house staff. Joint Commission Journal on Quality and Patient Safety, 34(10), 563-570.
31. Kowalsky, J., Nemeth, C. P., Brandwijk, M., and Cook, R. I. (2004). Understanding sign outs: Conversation analysis reveals ICU handoff content and form, Retrieved November 7, 2005, from http://www.ctlab.org/documents/Sccm2005%20POSTER.pdf
32. Lardner, R. (1996). Effective Shift Handover, Retrieved January 2, 2004, from http://www.hse.gov.uk/research/otopdf/1996/oto96003.pdf
33. Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(Suppl 1), i85-i90.
34. March, J. G. (1991). Exploration and exploitation in organizational learning. Organization Science, 2(1), 71-87.
35. Matthews, A. L., Harvey, C. M., Schuster, R. J., and Durso, F. T. (2002). Emergency physician to admitting physician handovers: An exploratory study. Paper presented at the Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting, Baltimore, MD.
36. Murphy, A. G., and Wears, R. L. (2009). The medium is the message: Communication and power in sign-outs. Annals of Emergency Medicine, 54(3), 379-380. doi: doi: 10.1016/j.annemergmed.2006.09.019
37. Nemeth, C., Kowalsky, J., Brandwijk, M., Kahana, M., Klock, P. A., and Cook, R. I. (2007). Between shifts: Healthcare communications in the PICU. In C. P. Nemeth (Ed.), Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace (pp. 135-154). Aldershot, U.K.: Ashgate.
38. Nemeth, C. P., O’Connor, M., Nunnally, M., Klock, P. A., and Cook, R. I. (2005). Distributed cognition: How hand-off communication actually works. Anesthesiology, 103, A1289.
39. Patterson, E. S., and Wears, R. L. (2010a). Measurement approaches for transitions of authority and responsibility during handoffs. In E. S. Patterson and J. Miller (Eds.), Macrocognition Metrics and Scenarios: Design and Evaluation for Real-World Teams (pp. 137-159). Farnham, U.K.: Ashgate.
40. Patterson, E. S., and Wears, R. L. (2010b). Patient handoffs: Standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety, 36(2), 52-61.
41. Petersen, L. A., Orav, E. J., Teich, J. M., O’Neil, A. C., and Brennan, T. A. (1998). Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Joint Commission Journal on Quality Improvement, 24(2), 77-87.
42. Philibert, I., and Leach, D. C. (2005). Re-framing continuity of care for this century. Quality and Safety in Health Care, 14(6), 394-396. doi: 10.1136/qshc.2004.011569
43. Propp, D. A. (2010). Improving handoffs in the emergency department. Annals of Emergency Medicine, 56(2), 204-205.
44. Randell, R., Wilson, S., Woodward, P., and Galliers, J. (2010). Beyond handover: Supporting awareness for continuous coverage. Cognition, Technology and Work, 12, 1-13. doi: 10.1007/s10111-010-0138-3
45. Salluzo, R. F., Mayer, T. A., Strauss, R. W., and Kidd, P. (1997). Emergency Department Management: Principles and Applications. St Louis, MO: Mosby.
46. Simon, H. A. (1971). Designing organizations for an information-rich world. In M. Greenberger (Ed.), Computers, Communications and the Public Interest (pp. 37-72). Baltimore, MD: The Johns Hopkins University Press.
47. Snow, V., Beck, D., Budnitz, T., Miller, D. C., Potter, J., Wears, R. L. et al. (2009). Transitions of care consensus policy statement: American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. Journal of General Internal Medicine, 24(8), 971-976. doi: 10.1007/s11606-009-0969-x
48. The Joint Commission. (2008). The National Patient Safety Goals Handbook. Chicago, IL: The Joint Commission.
49. Vidyarthi, A. (2004). Fumbled handoff, Retrieved December 21, 2005, from http://webmm.ahrq.gov/cases.aspx?caseID = 55
50. Wears, R. L., and Perry, S. J. (2010). Discourse and process analysis of shift change handoffs in emergency departments. Paper presented at the 54th Human Factors and Ergonomics Society, San Francisco, CA.
51. Wears, R. L., Perry, S. J., Shapiro, M., Beach, C., and Behara, R. (2003). Shift changes among emergency physicians: Best of times, worst of times. Paper presented at the Human Factors and Ergonomics Society 47th Annual Meeting, Denver, CO.
52. Westbrook, J. I., Coiera, E., Dunsmuir, W. T. M., Brown, B. M., Kelk, N., Paoloni, R. et al. (2010). The impact of interruptions on clinical task completion. Quality and Safety in Health Care, 19(4), 284-289. doi: 10.1136/qshc.2009.039255
53. Woods, D. D., and Cook, R. I. (1999). Perspectives on human error: Hindsight biases and local rationality. In F. T. Durso, R. S. Nickerson, R. W. Schvaneveldt, S. T. Dumais, D. S. Lindsay, and M. T. H. Chi (Eds.), Handbook of Applied Cognition (1st edn., pp. 141-171). New York: John Wiley and Sons.