Shift-to-Shift Handoff Research: Where Do We Go From Here?

Abstract

In 2001, the Institute of Medicine (IOM) reported that inadequate handoffs are “where safety often fails first.” 1 Other groups quickly joined the call for improved handoffs. The Joint Commission in 2006 added a new National Patient Safety Goal: improve the effectiveness of communication among caregivers and require hospitals to “implement a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.” 2 Also in 2006, the World Health Organization Collaborating Centre on Patient Safety (Solutions), the World Alliance for Patient Safety, and the Commonwealth Fund joined to launch the “High 5s” initiative, which includes prevention of patient care handoff errors.3 In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) enacted resident duty hour requirements to promote patient safety and resident well-being.4 However, these work restrictions have produced unintended consequences, such as an increase in frequency of handoffs, institution of night float systems, a shift mentality, and an increased risk of preventable adverse events associated with coverage by a physician from another team.5–,7 Further ACGME duty hour restrictions became effective in July 2011.8 For the first time, these included handoff requirements. Although referred to as “transitions of care,” the requirements mostly refer to handoffs (box 1). Box 1 Transitions of care (ie, shift-to-shift handoffs) in ACGME Common Program Requirementsa VI.B. Transitions of Care VI.B.1. Programs must design clinical assignments to minimize the number of transitions in patient care. VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. VI.B.3. Programs must ensure that residents are competent in communicating with team members in the hand-over process. VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient's care. The first of the new ACGME requirements is to minimize patient care transitions, which is complicated by the fact that both the 2003 and 2011 resident duty hour restrictions are likely to increase the frequency of inpatient handoffs. Most institutions have not utilized a formal teaching program to teach handoffs to residents. The 2011 transitions of care language clearly calls for structured instruction, evaluation, and monitoring of handoffs. As a result, residencies across the country are struggling with how best to accomplish these new requirements. This editorial outlines a research agenda for shift-to-shift handoffs in medicine.