Incomplete handoffs causing patient harm in a survey of medical and surgical house staff

In the October issue of The Joint Commission Journal on Quality and Patient Safety, patient handoffs that fail to provide clinicians with accurate and complete information are a significant source of patient harm. Researchers from Massachusetts General Hospital surveyed 238 medical or surgical residents during the study.

Fifty-nine percent of residents reported at least one incident of handoff-related patient harm during their last month-long rotation, with 12% reporting major patient harm, characterized by a significant worsening of clinical status, prolonged harm, disability, or death. See the abstract below.

Authors: Kitch, Barrett T.; Cooper, Jeffrey B.; Zapol, Warren M.; Marder, Jessica E.; Karson, Andrew; Hutter, Matt; Campbell, Eric G.

Source: Joint Commission Journal on Quality and Patient Safety, Volume 34, Number 10, October 2008 , pp. 563-570D(8)

Abstract :


· 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 handoff practices and the frequency with which they perceive problems with handoffs lead to patient harm.


· 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%).


· 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.


· 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.

(SOURCES: Advisory Board Daily Briefing ,, September 25, 2008; The Joint Commission Journal of Quality and Patient Safety [subscription required] ,, accessed September 27, 2008)