A patient receiving a wrong medication or wrong radiology study as result of patient misidentification is a clear example of a handoff that went wrong. A patient with a food allergy identified on the record, but is given the wrong meal and suffers an allergic reaction is another example of a handoff that went wrong.  A patient who is re-admitted to the hospital as result of not understanding and subsequently not following discharge instructions/meds properly also falls into the category of handoff that went wrong.   The opportunities for handoffs to go wrong are numerous, the severity of problems that can arise as result of improper handoff is huge, the solution to a successful handoff starts with you.

Handoffs in clinical practice is more than the passing of a patient from one caregiver to another.  It is the transfer of responsibility for a patient from one caregiver to another. 

The Joint Commission has reported that 65% of sentinel events were the result of communication breakdown.  To address this problem, the Joint Commission instituted a National Patient Safety Goal in 2006 calling on hospitals to implement a standardized approach to patient handoffs. 

Handoffs in patient care would seemingly be a simple process, but in reality it is complicated. Given so many variables, it leaves room for multiple opportunities to fail.  In hospitals, types of handoffs may include:

·         Nurse report at shift changes

·         Physicians transfer of on-call responsibilities

·         Relay of laboratory and radiology reports to care givers

·         Discharge summary information and/or instructions provided to patients or care givers. 

·         Patient transfer to different unit or facility

·         Temporary relief/change in caregiver.

The communication and shift in responsibility of a given patient or patient information is the responsibility of all caregivers. The goal is to improve communication and ensure continuum of patient care/patient safety.  There is no room for assumptions, speculation, or misinformation.  Every instance of communication or transfer of information/care must be timely and accurate.

Often when there is a sentinel event or breach in patient safety it is more than just one individual or one barrier that contributed to the problem. Barriers can include, at minimum, human, environmental, and physical factors. Lack of education, resistance to change, time restraints, lack of structure/standardization, a difference in communication styles, language barriers, interruptions, prejudice, hierarchy, and assumptions are just a few examples. Bottom line, each caregiver involved in a handoff (whether he/she is the giver or receiver) is responsible to ensure that a proper handoff was done.  Clinical handoff is more than information transfer; it is a transfer of professional responsibility. Communication during handoff should always be about the patient and continuum of his/her care. No hidden personal agendas, no emotional baggage, no power plays, no interruptions, nor assumptions should be made when handing off patient care. An opportunity for question and answers should always be provided to ensure accuracy and comprehension of information shared.

Effective handoffs should always be done face to face, when feasible. The handoff should be interactive- this allows for exchange of information not just “dump” of information. A key factor during a handoff is adequate time without interruptions. If necessary, you may need to control where and how the handoff is done. Obviously, the clearer you are with sharing information, both verbal and written, the better your chances are that the message was understood. However, given it is two way dialogue, you need to ensure that the receiver not just heard, but understands what you said. Always, allow for question/answer and repeat back period. The receiver needs to acknowledge what was said and accept responsibility for the patient and subsequent care. 

Patient safety starts with you! Communication is the key (whether it be written, verbal, or with body language) to patient safety and continuum of care. Often, the need to build in safety nets is necessary to ensure there is no breach. A very useful and successful tool is a checklist. This helps to reinforce standardization and ensure comprehensive hand offs. Being human there are opportunities to fail. Checklists help everyone to remember and act on best practices.