The term “handoff” refers to the transfer of patient care between healthcare providers for various reasons, including shift changes, referrals to specialists, transfers of patients within a healthcare organization or to other healthcare facilities, the provision of care by an on-call provider, etc.

Breakdowns in the handoff process have long been recognized as a common cause of medical errors. The Agency for Healthcare Research and Quality notes that handoffs and signouts (i.e., the act of transmitting information about a patient) have been linked to adverse clinical events in a range of healthcare settings.1

The risky nature of handoffs makes it imperative for healthcare organizations to devise effective strategies for transitioning the responsibility for patient care and transferring patient information. This checklist is designed to help healthcare providers and staff evaluate organizational handoff procedures and identify potential safety gaps.

Yes No

Has your organization identified situations in which transfers of care commonly occur in the course of patient care?

Has your organization asked staff for input about potential communication barriers or issues that might impede care transitions?

Does your organization have a written policy that describes the appropriate process for patient handoffs, including expectations for verbal and written communication?

Does the handoff policy specify the minimum requirements for what types of information need to be provided during a handoff (e.g., patient diagnosis, test/lab results, medical history, current stage of treatment, any recent changes in condition, potential complications that might occur, etc.)?

Has your organization established a detailed process for exchanging patient information during shift changes, on-call coverage situations, patient transfers within the organization, patient transfers to other healthcare facilities, and patient transfers to other providers (e.g., specialists)?

As part of developing handoff policies, has your organization considered the use of communication techniques (e.g., SBAR and I PASS THE BATON) and standardized checklists?

Checklist: Patient Handoffs 2

Yes No

Does your organization audit handoff processes to ensure that providers and staff are using appropriate forms, tools, and checklists?

Does your organization offer training in relation to handoff policies and protocols? Are providers and staff given the opportunity to clarify information and ask questions?

Has your organization established communication requirements related to on-call coverage, including (a) specific patient information that primary doctors should provide on-call doctors, and (b) expectations of on-call doctors for notifying patients’ primary providers about patient interactions and documenting phone calls in each patient’s health record?

Is a process in place for retrieving a daily list of callers from your organization’s answering service? Is this information reviewed and entered into each patient’s health record?

Do organizational policies designate responsibility for review, follow-up, and documentation of diagnostic tests results and lab orders? Do organizational systems support the necessary communication?

To learn more, watch MedPro’s video about handoffs in which Dr. Graham Billingham, Chief Medical Officer, discuss the complexity of care transitions and how healthcare providers and staff can address miscommunication risks.

1 The Agency for Healthcare Research and Quality. (2016, July). Patient safety primer: Handoffs and signouts.

Retrieved from http://psnet.ahrq.gov/primer.aspx?primerID=9

This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

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