Flawed patient handoffs often endanger hospital patients’ safety

The term "handoff" can bring to mind an NFL game where the quarterback hands the ball to a halfback on running plays. Flawless handoffs can be critical to the Detroit Lions' success on game day. Another type of handoff which needs to be flawlessly executed occurs in the context of hospitals. According to an article titled "Handoffs in Hospitals" published by the University of Michigan, medical handoffs are defined as episodes in which control of and responsibility for a patient passes from one health-care professional to another. Not surprisingly, it is absolutely critical that vital information about the patient be communicated to the health-care professional who is newly assuming responsibility for a patient.

Businessweek magazine reports that the moment when one clinician turns over care of a patient to another is "particularly hazardous." A surgeon who has written on hospital safety issues was quoted in the article as declaring that the patient handoff is, in fact, the most dangerous procedure in American hospital emergency rooms given that breakdowns in communications during handoffs are routine and commonplace.

The author of an article on patient handoffs published on the Johns Hopkins University website observes that, during handoffs, those assuming responsibility for a patient are supposed to be told the following critical information: (1) the current status of the patient; (2) the patient's prognosis; and (3) what medications the patient is taking or should be taking. The problem of flawed patient handoffs has been recognized for some time by medical academicians but has thus far proven "quite resistant to attempted remedies." One study discussed by the author indicates that, in a typical day, a lot of important information about patients is simply not communicated during handoffs. Among factors responsible for this lack of communication are distractions and interruptions that happen all too frequently in hospitals.

Medscape reports that life-changing errors in a patient handoff from one doctor to another are becoming more frequent. The potential for mishaps is quite possibly rising due to the increased fragmentation in medical care. Today, it is an increasingly rare occurrence that one physician will primarily attend to a patient throughout the entire course of their treatment in a hospital. After being admitted to a hospital, a patient is seen by several different hospitalists and at least a couple of specialists. When shifts change or one doctor refers a patient to another, "vital information often falls between the cracks." As team-based medical care becomes increasingly the norm in our hospitals, the odds increase of bad patient handoffs due to the miscommunication of vital patient information.


There are simple steps that could be taken to improve patient safety during handoffs. The Doctors Company-an insurer of physicians-suggests that all hospitals could benefit by requiring a "repeat-back" of the exchanged patient information at the time of a patient handoff. Further, all hospitals should require-at a minimum-that the following information be communicated during handoffs: (1) diagnoses; (2) current condition; (3) recent changes in condition; (4) anticipated changes; and (5) warning signs of changes in the patient's condition. Importantly, interruptions and distractions should be kept to a minimum during handoffs.

Seeking compensation

If you or a loved one has been injured due to the negligence of health-care providers, you should contact a Michigan attorney experienced in handling medical malpractice claims. Do not allow yourself to be the innocent victim of a flawed hospital handoff due to the failure of health-care professionals to pass along critical information about your condition.