The patient handoff—the transfer of patient related health information from one caregiver to another—has come under increased scrutiny in recent years. This is due to many factors including high-profile and well documented incidents of medical errors, a subsequent magnified focus on patient safety by the general public, and changes in resident work hours which have had the unintentional consequence of increasing the number of necessary handoffs during a given patient hospitalization. As medical care becomes more specialized and increasingly fragmented, handoffs are necessary in order to maintain consistency of information and plans of care. However, despite this increased focus, errors in transferring medical information are still common. In order to meet standards, many training organizations and medical institutions mandate lengthy handoffs at all levels. While initial studies demonstrated a decrease in medical errors after implementation of a standardized handoff bundle, more recent evidence calls into question those results. Certainly many components are necessary, can improve handoff communications, and reduce errors during a patient sign-out. However, more is not always better, and caregivers should not blindly attempt to transfer information unless there is medical necessity. Achieving a balance between “safe” and “effective” communication is the goal that we are still trying to achieve.
Part of the book: Vignettes in Patient Safety