Miscommunication during ED handoffs paves the way for patient harm opportunities

Patient Safety Monitor Insider

September 30, 2015

Over the last decade, patient handoff procedures have become an integral part of the patient care process, accompanied by a slew of acronyms and standardized procedures meant to improve continuity of care and prevent patient errors.


However, many of these models focus on intra-unit handoffs, particularly during change of shift. Meanwhile, handoffs that occur from one unit to another most frequently from the emergency department (ED) to an inpatient unit have received significantly less attention despite the risk of potentially dangerous adverse events.

A recent survey published in the July issue of the Journal of Hospital Medicine indicates that the handoff exchange between ED physicians and admitting doctors is frequently wrought with patient safety risks born from miscommunication. The survey polled admitting and ED physicians at the University of Nebraska Medical Center in Omaha looking at communication quality, clinical information, interpersonal perceptions, assignment of responsibilities, organizational factors, and patient safety. Twenty-nine percent of physicians indicated that adverse events were a result of ineffective communication during the handoff process, and 78% indicated that sequential handoffs negatively impacted patient care.


Furthermore, 34% of admitting physicians and 19% of ED physicians reported that a patient was harmed in the previous three months because of problems during the handoff from the ED. More than half of those that reported patient harm cited two or more examples.


The survey offers a peek at some of the major issues tied to inter-unit handoffs, particularly when it comes to physician communication, says Christopher Smith, MD, assistant professor of internal medicine in the division of general internal medicine at the University of Nebraska Medical Center, and lead author of the study. Given the overwhelming patient safety concerns, he hopes the study offers a jumping-off point for hospitals to identify ways in which they can improve this particular process.


Continue reading this article in the Patient Safety Monitor Journal. Visit here to login or subscribe.