Handoffs causing patient harm: A survey of medical and surgical house staff
MedSun: Newsletter #34, March 2009

By: Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG.

BACKGROUND: Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their hand-off-practices and the frequency with which they perceive problems with handoffs lead to patient harm.

METHODS: A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%).

RESULTS: Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always.

DISCUSSION: Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.

For additional information, visit PubMed, a service of the U.S. National Library of Medicine and the National Institutes of Health.

Also visit December 2008’s Premier Inc. SafetyShare Newsletter for a summation of this study. You will find a direct link in Additional Information below.

Additional Information:

Handoffs causing patient harm: a survey of medical and surgical house staff. Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG. PubMed. October 2008.

Handoffs a Significant Source of Patient Harm; Interruptions and Noise Prevent Communication of Crucial Information. SafetyShare Newsletter, Premier, Inc. December 2008.

MedSun Newsletters are available at www.fda.gov/cdrh/medsun