Page 22 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

timing, and lack of time or staff.

“The consequences of substandard handoffs may include

delay in treatment, inappropriate treatment, adverse events,
omission of care, increased hospital length of stay, avoidable

readmissions, increased costs, inefficiency from rework, and
other minor or major patient harm. “

- Joint Commission Center for Transforming Healthcare

According to the Agency for Healthcare Research and Quality,

the handoff process should include the following:

• Interactive communications (include the patient and family

in the process)

• Limited interruptions (reduce noise, avoid competing

priorities)

• A process for verification (obtain adequate and verified
information about the patient)

• An opportunity to review any relevant historical data 9

The emergence of hospitalists has improved inpatient care
but not without presenting potential patient safety and
liability issues. Breakdown in communication and incomplete

transfer at hospital discharge are common factors leading to

medical errors, poor patient outcomes, and liability claims. For
physicians who handoff hospital care to a hospitalist, a formal
agreement with expectations for communication can reduce the

9 Agency for Healthcare Research and Quality. Patient safety primers: handoffs and signouts.
Available at: http://psnet.ahrq.gov/primer.aspx?primerID=9

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