Patient handoffs across units need improvement

Process needs to happen every time and everywhere

Almost half of hospital staff report there is room for improvement in the area of handoffs and transitions across units, according to the 2007 Hospital Survey on Patient Safety Culture Comparative Database Report released by the Agency for Healthcare Research and Quality (AHRQ).

More than three-fourths (78%) of hospital staff believe there is a positive environment of teamwork within their units, but nearly half (45%) indicate there is room for improvement in the area of handoffs and transitions across units.

"Having worked in this area a lot, it was what we expected, but other people may find this surprising," says James B. Battles, PhD, senior service fellow for patient safety at AHRQ. "Teamwork may be viewed positively, but across work areas it may not be as strong as we would like. This data shows that you're not alone."

Handoffs may go smoothly in one clinical unit, but when the patient moves to another area, such as going to the intensive care unit from the emergency department, problems often occur.

The report is the first compilation of aggregated national data from AHRQ's Hospital Survey on Patient Safety Culture. It is based on data from 382 U.S. hospitals and survey responses from 108,621 hospital staff. The report found a number of strengths among hospitals, as well as areas for patient safety culture improvement, such as handoff communication.

"I would say we are still reasonably early in this work," says Michael Leonard, MD, physician leader for patient safety at Kaiser Permanente in Evergreen, CO. "The awareness that it needs to happen is pretty high. We certainly know from Joint Commission data that the majority of things that go astray are related to handoffs."

The organization must decide what tool or technique to use for handing off, whether Situation-Background-Assessment-Recommendation (SBAR) or another model. "The really critical piece is the cultural agreement that it needs to happen every time and it needs to happen everywhere," says Leonard.

"Typically, people hand off in different ways. What you need is a standardized model that allows for the nuances of a particular environment. You have to build a system that supports that behavior and says it's not negotiable — that this is something that happens, always."

Handoffs should be done so consistently that the process becomes "the way we do business," says Leonard. "In medicine, there are many great tools and protocols that are used only a very small percentage of the time," he notes. He contrasts this with two pilots on the flight deck of an airplane who go through a checklist 100% of the time, and start over if they are interrupted. "What we need to do is to give people both practical tools and the leadership component."

For high-risk handoff areas, communication errors could lead to adverse events or even the loss of a patient's life. Researchers at Children's Hospital in Boston evaluated the handoff process for children who undergo surgical intervention and then return to the pediatric intensive care unit (PICU). A lot of variability in the process was identified, says Kshitij P. Mistry, MD, MSc, lead author and assistant professor of pediatric critical care medicine at Duke Children's Hospital in Durham, NC.1

Two other key findings were that the PICU environment is not conducive to good communication because of constant distractions from pagers and alarms, and also, that all the relevant providers pertinent to a patient's care were not present during the handoff.

When Mistry and his colleagues set out to improve the PICU handoff process, they first compared the information content of the current handoff process to what was ideal. "What we have done at Duke is try to address those deficiencies," he says. Six Sigma methodology was used, with the goal of decreasing the variability of the handoff process.

The hospital's PICU has 1,200 admissions a year, 30% of which are children with congenital heart disease. "That seemed like a logical patient population to start with. Given the high degree of complexity of these patients, they are at high risk for adverse events due to communication errors," says Mistry. These steps now occur every time a child who has undergone surgery for congenital heart disease surgery comes back from the operating room to the PICU:

All health care providers are present at the bedside, including not only the critical care nurse and physician, but also a representative from cardiothoracic surgery and cardiac anesthesia.

The concept of "sterile cockpit" from aviation is used, meaning that nonessential conversation does not occur during takeoff and landing, which are the times of greatest risk for crashes. "We applied that to handoffs," says Mistry. "When it is time for us to communicate information verbally, no nonessential conversation occurs."

Individuals talk in a specific order. First, the cardiothoracic surgeon explains what they did in the OR and what they are concerned about. Next, anesthesia gives their input, and lastly, critical care physicians and other team members ask questions. "So we all create a shared mental model of what this patient's trajectory should be," says Mistry.

Long-term outcomes, length of stay, and adverse outcomes are still being evaluated to find out the impact of the new handoff process. "Thankfully, our mortality rate is small, so that might not be the most sensitive indicator for us," says Mistry. However, the hospital's data show that delays in time-sensitive therapies, such as a chest X-rays and critical lab results, have decreased.

"So we can employ interventions faster, and place these patients on appropriate cardiorespiratory monitoring," says Mistry. "We are hoping that the timeliness of therapy will improve care, and, therefore, decrease morbidity and mortality."'

The organization is implementing the new handoff process for neurosurgical patients coming back to the intensive care unit (ICU) from surgery, and patients going to a non-critical care setting from the PICU. Often, the health care providers receiving the patient have not been involved in the patient's ICU care, so that is another communication gap potentially leading to adverse events, says Mistry.

Process improvement is often considered "soft science" because it's hard to have objective outcomes to measure, says Mistry. "I think that has been the biggest obstacle so far. But now people will see the improvement in patient outcomes related to improving the process," he says. "So I think that people will start to employ these interventions. For us, that has been the tipping point."

(Editor's note: A downloadable copy of the 2007 report is available on the AHRQ web site at


  1. Mistry, KP, Landrigan, CP, Goldman DA, et al. Communication error during post-operative patient hand off in the pediatric intensive care unit. Critical Care Medicine 2005: 33(12);A12.

[For more information, contact:

James B. Battles, PhD, Senior Service Fellow for Patient Safety, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. Phone: (301) 427-1332. Fax: (301) 427-1341. E-mail:

Michael Leonard, MD, Physician Leader for Patient Safety, Kaiser Permanente, Evergreen, CO. 1152 Woodland Lane, Evergreen, CO 80439. Phone: (303) 670-1342. Fax: (303) 670-0302. E-mail:

Kshitij P. Mistry, MD, MSc, Associate in Pediatrics, Pediatric Critical Care Medicine, Duke Children's Hospital, DUMC Box 3046, Durham, NC 27710. Phone: (919) 681-3550. Fax: (919) 681-8357. E-mail:]