Patient handoffs: The gap where mistakes are made

A patient handoff (also known as transitioning) is both the act of passing a patient between caregivers and the information exchanged between the sender (the provider giving away the patient) and the receiver (the provider taking the patient).

These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine.

This exchange is a huge weak point in healthcare; each handoff runs the risk of having key treatment information being garbled, forgotten, or not passed on. On September 12, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and their effect on patient care.

“Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. “When hand-off communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few.”

Christopher Landrigan, MD, MPH, research director of inpatient pediatrics at Boston Children’s Hospital and the principal investigator of the I-PASS study on patient handoffs, says that just by looking at the data on the role communication plays in medical errors, one can see how huge an impact handoff can have.

“Our best estimates are that 150,000-250,000 patients are killed each year in the U.S. as a consequence of adverse events, which are injuries due to medical care,” he says. “In data that’s been gathered by The Joint Commission, Department of Defense, and other agencies, communication is a leading cause of sentinel events, which are the most serious adverse events. All told, communication failures contribute to somewhere between 50% to 80% of sentinel events. So it’s the number one cause of the most serious events in hospitals which in turn are a leading cause of death in the U.S.”

Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, explains that the information provided during a handoff is key in ensuring a seamless transition of patient care.

“Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information,” she says. “Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.”

Part of the problem, she says, is that handoff procedures can vary widely within and between facilities, if they are done at all. While there are several good models and formats for healthcare organizations to adapt and develop, like SBAR and I-PASS, it’s up to facilities to adopt and tailor them for their needs.

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