Fumbled Handoffs at Shift Change: A Common Liability Source for Emergency Physicians

Don't rush to leave the department, take "ownership" of new patients

By Robert A. Bitterman, MD, JD, FACEP, Contributing Editor

Patient handoffs, or turning over a patient's care to another physician, are high-risk encounters in emergency medicine due to the potential for breakdowns in communication. Important information may not be provided, the information provided may be misunderstood, or the physician assuming care of the patient may forget the information. Any of these issues can lead to misdiagnoses, adverse outcomes, unhappy patients or families, and litigation for malpractice.

The Institute of Medicine, in its seminal report, Crossing the Quality Chasm, specifically cited patient handoffs as one of the most common sources of error in medicine.1 Recent studies also confirm that poor communication is the leading cause of sentinel events within hospitals.2 The malpractice literature corroborates that communication breakdowns occurred in nearly 80% of medical malpractice lawsuits.3 In response, The Joint Commission identified improvement in patient turnover communications as one of its prime patient safety goals in 2006.4

In the practice of emergency medicine, handoffs occur in three typical scenarios: first, at change of shift from one emergency physician to another; second, at the time of admission from an emergency physician to the admitting physician; and third, at the time of transfer from an emergency physician at one hospital to an accepting physician at another facility. This article will focus on the change of shift in the ED, though the concepts are equally applicable to the other scenarios as well.

Patient Handoffs between ED Physicians at Shift Change

At shift change, the emergency physician going off-shift may be tired or in a rush to leave the department. The oncoming physician may never examine the patients transferred to their care or really develop a sense of "ownership" for them during their stay. It's often expedient to simply accept the patient's data, without critically questioning the prior physician or obtaining a complete picture of the patient's situation, to be able to begin seeing the new patients who may be crowding into the ED. Failure to allocate enough time to handoffs is a common reason for mistakes. Add high volume, high acuity, a noisy chaotic environment, and a compounding effect when both the nursing staff and physicians change shift simultaneously, and it's easy to see the propensity for error.5

Role of the emergency physician turning over patients to an oncoming emergency physician. The principal role of the physician leaving the ED is to adequately communicate the existing and foreseeable needs of the patients, the plan of care, and any potential complications to the oncoming emergency physician. The physician ending his/her shift should document the transfer of responsibility to the oncoming physician and the exact time that the transfer of responsibility took place in the ED records. He or she should inform the patient and family of the change in physicians, and build in additional redundancy by telling the patient's nurse that a transfer of care had taken place — and who will be responsible for the patient henceforth. Physicians definitely want to avoid the embarrassing and dangerous scenario of a patient "nose-diving" shortly after shift change and no one in the department knowing which physician is responsible for the patient.

Handoff of the complex patient. There are essentially two types of patients turned over at change of shift. First, is the complex work-up type patient who requires considerable attention from the managing physician. In this case, the leaving physician should bring the oncoming physician to the patient's bedside to introduce the physician to the patient and point out key findings or concerns to ensure a seamless transfer of care.

Handoff of the patient with less complicated complaints. The second type includes the "simple action" cases, for which only 1-2 straightforward actions need to be taken that are usually based on a lab test or x-ray result. For example, x-ray may be delayed and the patient needs a simple ankle x-ray that the physician expects to be negative. The emergency physician who originally saw the patient should explain the situation to the patient (and family if present), provide the appropriate care and discharge instructions relative to a negative result, and prepare the necessary discharge materials and prescriptions. Then, if indeed the x-ray is negative the oncoming physician can so inform the patient and ask the nursing staff to discharge the patient.

The question that always comes up in these types of cases is whether the on-coming physician should write a note and sign the medical record? If only a simple straightforward action is necessary, such as checking an x-ray or lab result, then the on-coming physician can perform the task requested for the physician leaving the ED and not sign the chart. Usually, the leaving physician retains sole liability for the patient's care and outcome. If the oncoming emergency physician, rather than a radiologist, reads the x-ray, then the emergency physician should reexamine the patient, write a note on the chart, and sign the chart indicating the actions taken and responsibility assumed.

Certainly, whenever a lab test is abnormal or an x-ray is positive in any way, the oncoming emergency physician should speak to the patient, explain the finding, and arrange the appropriate care or follow-up needed. The physician also should write a note documenting the findings and communications with the patient and sign the ED record.

Remember to slow down during turnover times. Finally, don't be in a rush to leave the emergency department; accept it as part of your life and just plan on being there awhile. Doing so will eliminate a great deal of your own anxiety and markedly improve the quality of care for your patients. Similarly, don't schedule meetings for at least an hour to an hour and a half after your shift ends (depending on the patient volume and acuity of your ED). If you must rush out, ask the oncoming physician to come in early and repay the time to him or her later on.

Many ED groups schedule overlapping shifts, or during double-covered times have physicians who are near the end of a shift only pick up lower acuity patients to mitigate turnover issues. Consider innovative systems to minimize the number of turnovers and accordingly minimize the risk!

Role of the oncoming emergency physician. The oncoming physician should not merely "receive report," but instead actively illicit information, ask clarifying questions, and highlight contradictions or inconsistencies. Ask "if-then" questions to understand the patient's expected course in the ED. Try to quickly see the more complex patients while the off-duty physician is still in the ED in case you identify additional questions or concerns.

Accept "real" responsibility for the patient; introduce yourself to the patient and family, inform them of your role for the remainder of their visit, and assure them that you've fully discussed the patient's case with the initial physician. Then, take care of the patient as if no one else had been involved in their care except you.

Don't always assume the initial diagnosis or x-ray interpretations were correct. If needed, reassess the patient sufficiently to the point that you are satisfied you understand and have a handle on the patient's medical conditions. Be especially leery if you are assuming care of a complex or intoxicated patient from the night physician; disrupted circadian sleep patterns may lead to aberrant medical decision making. The passage of time and a fresh, full evaluation of the patient may reveal additional concerns.

As a general rule, all patients assumed at change of shift should be reevaluated prior to discharge. The "simple-action" type turnover patients may sometimes be an exception, as was noted previously in this article. Certainly, any patients who are in the department a long time, even the straightforward patients, also should be reassessed at the time of discharge. The oncoming physician always should write a note documenting the reassessment, any change in the patient's condition, and the final diagnosis and discharge instructions.

Policy Perspectives on ED Shift Change

If your ED physician group works in a fee-for-service or RVU (relative value unit) model, it is highly recommended that the group assign payment for the patient encounter to the physician who last signs the chart and is responsible for discharging the patient. This physician is the one who accepts ultimate responsibility and liability for the patient's care and disposition. Such a policy truly encourages "real ownership" of the patients who are turned over at change of shift and also diminishes the number of patients ultimately signed out to the oncoming physician.

The shift change process itself should be standardized and include an opportunity to ask and respond to questions. "Sticky note" instructions left on a chart are unacceptable. Face-to-face discussion of the patients' issues using departmental standardized procedures such as checklists, sign-out cards, or computerized grease boards improves the transition of care and minimizes miscommunications and errors. Patients always should be discussed in a standard order, such as starting and ending at the same bed location in the department, to avoid omitting anyone.

Standard policy and procedure should define a bright-line transfer of responsibility from emergency physician to emergency physician by requiring the leaving physician to document and note the time of the transfer of care to the oncoming physician in the ED medical record. Policy and procedure should require the oncoming physician to reassess all patients who are assumed, write a final note on the record, and sign the chart. (Again, the "simple-action" type cases maybe an exception to this rule.)

Policy also should require that the patient, the family, and the patient's nurse be promptly informed of the change in the responsible emergency physician so that everyone knows who is in charge of the patient's care at all times.


The key to a successful risk management program is to commit energy and resources to areas of known risk. Patient handoffs at change of shift in the ED are definitely high-risk encounters and prone to communication errors. Awareness of the particular risks of each scenario, implementing formal transition policies and procedures, and improved communication processes will minimize the medical and legal problems related to the handoff.


1. Committee on the Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The National Academies Press; 2001.

2. WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions. May 2007, Volume 1, Solution 3. [Identified poor communication as the leading root cause of sentinel events in hospitals.]

3. Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA 1994;272:1619-1620. [Communication breakdowns evident in 80% of malpractice lawsuits.]

4. The Joint Commission. 2006 National Patient Safety Goals. Goal 2E: Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. Joint Commission Perspectives July 2005.

5. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med 2005;142:352-358; Meisel ZF, Pollack C. Patient safety in emergency care transitions. (Case study). Emergency Medicine Specialty Reports. June 2006.

Additional Resources

1. Joint Commission International Center for Patient Safety. Strategies to improve hand-off communication: implementing a process to resolve questions. Joint Commission Perspectives on Patient Safety July 2005, Volume 5, Issue 7. Available at http://www.jcipatientsafety.org/15274. Accessed on 2/6/08.

2. Behara R, Wears R, Perry SJ, et al. A conceptual framework for studying the safety of transitions in emergency care. Advances in Patient Safety, vol 2. http://www.ahrq.gov/downloads/pub/advances/vol2/Behara.pdf. Accessed on 2/6/08.

3. Wears RL, Perry SJ, Shapiro M, et al. Shift changes among emergency physicians: best of times, worst of times. In: Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting. Denver, CO: Human Factors and Ergonomics Society; 2003:1420-1423.

4. Burrell M. Shift report: Improving a complex process to enhance patient safety. ASHRM J 2006;26:9-13.

5. Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-266.

6. Arora V, Johnson J, Lovinger D, et al. Communications failures in patient sign-out and suggestions for improvement: a critical incident technique. Qual Saf Health Care 2005;14:401-407.

7. Patterson E.S., et al.: Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16:125-132.

8. Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791-794.

9. Wachter RM, Shojania KG. Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes. New York, NY: Rugged Land Press; 2004.