Practice of Medicine


Improving Patient Handoffs Improves Patient Safety

Executive Summary

Poorly executed patient handoffs result in a disproportionate number of patient safety events. Handoffs should be documented descriptions of critical patient data communicated in an adequate and consistent manner. Improving the handoff process will improve patient care and safety.

Recommended Actions
  • Determine what triggers different types of handoffs and how much time is needed for effective communication of each handoff.
  • When engaged in a handoff, provide written patient summaries that include descriptions of critical and relevant data.
  • Utilize a patient handoff checklist to guide important communication of patient data.

Handoffs are a necessary part of patient care. These transfers of information, authority and responsibility occur whenever a provider changes, when a patient is transferred from one unit to another, before and after a procedure, and at admission and discharge. 

Handoffs account for a disproportionate number of patient safety events. According to a Joint Commission analysis, communication errors account for nearly 70% of sentinel events and at least half of those errors occur during handoffs.

Given the importance of this common occurrence, what are some methods providers can use to improve communication during handoffs and ensure patient safety? Here are a few ideas:

1.     Determine what will trigger a handoff.

Obvious times for a handoff include a shift change or a patient move to a different unit. Other opportunities for handoffs include critical diagnostic test results, a physician to nurse handoff, and whenever an event, such as the Rapid Response Team activation, occurs for a patient.

2.     Ensure adequate time for handoffs.

Time should be set aside and protected for communication of handoff information. This time should be consistent; it could be five minutes before the change of a shift, whenever a patient leaves the unit for a diagnostic study, whenever a patient is admitted, etc. Whatever the time or triggering event chosen, it should be consistently applied.

3.     Ensure adequate space for handoffs.

Patient handoffs should optimally be done face-to-face, in a quiet setting that promotes giving and receiving important information. While the face-to-face handoff with written material is the gold standard, there may be times when it is not possible and other methods, such as email, texting, computer-generated documents or the EHR must be used in the handoff. If this is the case, providers must confirm that the next provider received and understood critical information.

4.     Include critical data.

This may vary by practice setting but would likely include a patient summary, appraisal of illness severity, pending tests/studies/procedures and contingency plans (“if/then” statements; “if” the hemoglobin is below 7 “then” transfuse one unit of packed red blood cells). This data should be read back by the receiver to verify.

5.     Employ a communication checklist.

An example of this is SBAR: Situation, Background, Assessment and Recommendation. There are numerous others available as well. It's less important which one you use; it's more important that the participants are familiar with the checklist and use it in a consistent fashion.

6.     Establish adequate communication.

The patient handoff is not a one-way street. The provider who is receiving the handoff must be an active listener, willing to ask questions and be able to read back the information given to confirm accuracy.

7.     Evaluate the handoff process.

Periodically review the patient handoff process on various units. What works? What doesn’t?  Does the staff feel there are any additions to the handoff that would make it more effective?

8.     Standardize!

Variability in the handoff process increases the risk of miscommunication between providers, which increases the risk of patient harm. All of the items above can be standardized, which will not only improve the handoff but will make the handoff process more efficient.

Finally, the handoff isn’t complete until it is documented. The time of the handoff, the participants and the data exchanged all should be reflected in the chart. Improving the handoff process will improve both patient care and patient safety.

Lessons Learned
  • Consider implementing a checklist for each handoff that employs the elements of SBAR: Situation, Background, Assessment and Recommendation.
  • Re-evaluate the handoff process periodically based on provider feedback and implement changes as necessary.
  • Offer the provider who is receiving the handoff a checklist to follow, including questions to ask and information they should receive regarding the patient.
Potential Damages

Errors in patient handoffs are a significant cause of patient safety events and can lead to severe patient harm. Healthcare organizations and providers run the risk of litigation for negligent care if they execute inefficient and mismanaged patient handoffs. Defending against such claims and compensating patients injured because of provider hand-off errors can quickly add up.


1. Every type of handoff requires communication of the same patient data.
2. Handoffs are a two-way street.
3. Handoffs must be documented.


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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.