1. Rosenberg, Karen
  2. Kayyali, Andrea MSN, RN


* Implementation of a standardized handoff process in children's hospitals reduced the number of handoff-related care failures.



Article Content

Accurate and efficient patient handoffs, which involve the transfer of information, responsibility, and authority between health care providers and units, are crucial for patient safety. Researchers evaluated the effect of a multihospital quality improvement collaborative designed to reduce handoff-related care failures in children's hospitals.


Twenty-three children's hospitals participated in the collaborative, developing a pediatrics-specific "change package of evidence-based practices used to guide sites in improving handoffs." At each site, four key elements were identified, irrespective of handoff type: a "defined handoff intent" (shared goals regarding handoffs), the "defined handoff content" (including the "core and unique elements of a given handoff type"), a "defined handoff process" (including tools and methods, a handoff format, and clear and timely transition of responsibility), and "maximized team effectiveness" (leadership was established and "team building tools" were used to "develop a culture of safe handoffs"). Handoff-related care failures, defined as failures in information transfer that directly affected the patient or delayed or complicated patient care, during the baseline and three intervention periods were compared.


During the 12-month study period, 7,864 handoffs were evaluated. The incidence of handoff-related care failures decreased 69%, from 26% of handoffs at baseline (the first three months) to 8% by the final quarter. Significant improvements in all types of handoffs were achieved. Compliance with all three handoff-process measures (no interruptions or distractions, mutual understanding of the patient, and formal acceptance of responsibility) improved from 87% at baseline to 94% in the final intervention quarter. Providers' satisfaction with the handoff process also increased, from 55% at baseline to 70% in the final quarter.


The authors speculate that a reduction in errors resulting from improved handoff processes will lead to a reduction in handoff-related patient harm.-KR




Bigham MT, et al. Pediatrics. 2014;134(2):e572-e579