Smooth Transitions: The Importance of Handoffs for Continuity of Care March 6, 2025 Practice Management, RCMA/CMA, Resources, Risk Management Business Partner, ProAssurance, RCMA, Resources, Risk Management 0 This informative article is provided by ProAssurance Download Article By Gerryann Whalen, BS, RN, CPHRM, OCN Introduction The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first.”1 A handoff is a complex process that can happen thousands of times a day in a busy hospital or ambulatory care center. Handoffs occur all along the continuum of patient care between many different members of a healthcare team and across many different locations of care. Elements of an Effective Handoff Process A successful handoff process increases patient safety and can decrease liability risk through a combination of accurate transfer of patient information and clearly stated practitioner responsibilities. Handoff is a time for a healthcare provider (HCP) to raise concerns, but factors such as hierarchy and organizational culture can negatively impact team members’ willingness to speak up.2 Physician leadership’s demonstrated commitment to standardizing a handoff process includes fostering a workplace culture in which members of the healthcare team respect each other and value teamwork. Additionally, an effective handoff process includes:3,4 Involvement of end-users in the development and evaluation of handoff processes and tools. Consistency (e.g., information is updated in the same way at every handoff). Face-to-face handoff communication whenever possible. Adequate time for meaningful exchange, free from interruptions. Multidisciplinary input, including bedside handoff with patient and family involvement. Use of closed-loop communication to share information and verify the message is understood.5 Standardized communication tools such as Situation, Background, Assessment, Recommendation (SBAR) or Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next (IPASStheBATON). A clear transfer point of patient responsibility from one provider to another. Ongoing monitoring and evaluation of the effectiveness of the process. The primary goal of the handoff is to accurately and consistently transfer patient information in a way that provides an oncoming clinician the most current patient status to ensure continuity of care and patient safety. Each transition of care during a hospitalization can increase the risk of a patient harm event occurring. It has been estimated by one teaching hospital that it experiences nearly 4,000 handoffs or transitions of care per day (1.6 million per year).6 That presents a staggering number of opportunities for error. The key to handoffs is consistency.7 Inadequate, disorganized handoffs add to patient dissatisfaction. Studies have shown that it is not necessarily only substandard medical care that leads patients to file a malpractice lawsuit. In many cases patients are simply angry about the way they were treated8 or the lack of communication they received, or they had unrealistic expectations around outcomes. Case Study: Who's the "Captain of the Ship?" On March 2 a 75-year-old woman presented to her family physician (FP) complaining of a persistent cough, dyspnea, night sweats, and cachexia for approximately one year. The FP ordered a chest x-ray, which showed a right middle lobe infiltrate and a right pleural effusion. He suspected pneumonia, so a sputum culture was sent, and the patient was started on antibiotics. When the patient’s symptoms did not improve, the FP referred the patient to an infectious disease (ID) specialist. The ID specialist started the patient on several broad-spectrum antibiotics and ordered blood cultures, serum antibody tests, and antigen tests to determine the cause of the patient's pneumonia. However, none of the tests were definitive. On May 3 the patient's dyspnea continued to worsen, and the ID specialist referred the patient to a pulmonologist for a bronchoscopy. The pulmonologist sent out additional specimens, including for acid-fast bacilli stain and culture (AFB). The AFB would take up to six weeks to return, but all other tests were normal. On May 4 the FP received the results of the March sputum culture that was sent by her office. Findings were positive for Mycobacterium avium complex (MAC). The FP assumed the patient was still being followed by the ID specialist and filed the report with no further action. On May 15 the pulmonologist referred the patient back to the ID specialist, advising him of the normal study results he had received. There was no mention that the AFB results were still outstanding. On June 8 the pulmonologist received the AFB results from the bronchoscopy which confirmed growth of MAC. The pulmonologist believed it was the ID specialist's responsibility to follow up on the bronchoscopy culture results and did not communicate the AFB results to the ID specialist. In October, over four months later, the patient developed low-grade fevers. The ID specialist referred the patient back to the pulmonologist on two separate occasions, but the pulmonologist never mentioned the AFB test results in his consultation reports. In December the patient was admitted to the hospital for respiratory failure and expired within the week. The family filed a wrongful death lawsuit against the FP, pulmonologist, and ID specialist alleging failure to diagnose and treat MAC. Discussion Consistently safe and effective handoffs require active participation by all healthcare team members. Sometimes circumstances may require the receiving provider to research further when handoff communication is lacking. Relying only on information that is pushed forward can result in important information being overlooked. Infectious Disease Specialist Experts disagreed about whether the FP or the ID specialist was the "captain of the ship,” but it was generally agreed that the ID specialist had the most liability exposure. Experts were critical of the ID specialist for failing to follow up on the culture results from the FP and pulmonologist. The ID specialist should have obtained those results when they were not in the file. Failure to obtain the results was especially problematic when the patient was not recovering, and the physician did not have an etiology for the patient's problem. Pulmonologist Experts were critical of the pulmonologist for failing to communicate with the ID specialist regarding the bronchoscopy results. Experts believed that because the pulmonologist received the results from the lab, it was incumbent on him to ensure appropriate follow-up or sign off on the case and delegate responsibility to someone else for follow-up. Family Physician Experts’ opinions were mixed regarding the FP's treatment of the patient. His main area of exposure related to failing to bring the sputum culture results to the attention of the ID specialist. Risk Reduction Strategies Consider the following recommendations:9 Referring Physicians Have an office policy and tracking system in place for ensuring that you review results of ordered tests and consultants’ reports. Determine whether you, the consulting physician, or a different physician will coordinate follow-up treatment and ensure agreement from all. Clearly establish expectations regarding communication and levels of anticipated involvement in the patient’s care. Ask the specialist to copy you on study results, consultation reports, and other information that will be important for the patient's ongoing care. Continue to follow up with your patient after referral until a diagnosis and treatment plan is established. Specialists When a referring physician hands off a patient with incomplete information, make efforts to obtain the information necessary. Don’t hesitate to call the referring physician directly to discuss tests results, your impressions, and recommendations, especially on complex cases. Before signing off on a consultation, ensure you have reviewed the final report and that the patient and referring physician are aware of any required follow-up appointments and who will be coordinating care going forward. Conclusion Consistent handoff practices can improve a clinician's ability to provide quality care, increase patient safety and patient satisfaction, and decrease liability risk. Informing patients of their diagnoses and telling them who will be coordinating their care creates a handoff communication safety net. Implementing easy-to-use handoff tools and policies can result in better continuity of care for patients and clearer communication and teamwork among healthcare teams. Taking time to regularly evaluate handoff practices is an important part of ensuring it is a routine practice that continues to meet the needs of each unique healthcare setting. Endnotes Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, D.C.: The National Academies Press, 2001), https://doi.org/10.17226/10027; https://nap.nationalacademies.org/read/10027/chapter/1. “Communicating Clearly and Effectively to Patients: How to Overcome Common Communication Challenges In Health Care,” Joint Commission International, 2018, https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-final_(1).pdf. Essi Vehvilainen et al. “Influences of Leadership, Organizational Culture, and Hierarchy on Raising Concerns About Patient Deterioration: A Qualitative Study,” Journal of Patient Safety 20, no. 5 (August 2024): e73-e77, https://doi.org/10.1097/pts.0000000000001234. “Sentinel Event Alert Issue 58: Inadequate Hand-Off Communication,” The Joint Commission, 2017, https://www.jointcommission.org/-/media/tjc/newsletters/sea-58-hand-off-comm-9-6-17-final2.pdf. “Closed-Loop Communication,” image in TeamSTEPPS® 3.0 Pocket Guide: Team Strategies & Tools to Enhance Performance & Patient Safety, 6, Agency for Healthcare Research and Quality, revised May 2023, https://www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf. Arpana R. Vidyarthi, “Triple Handoff,” PSNet, Agency for Healthcare Quality and Research, September 1, 2006, https://psnet.ahrq.gov/web-mm/triple-handoff. “Handoff: Use a Handoff Tool for Optimal Patient Transitions of Care,” American Hospital Association Center for Health Innovation, https://www.aha.org/center/project-firstline/teamstepps-video-toolkit/handoff. Beth Huntington and Nettie Kuhn, “Communication Gaffes: A Root Cause of Malpractice Claims,“ Baylor University Medical Center Proceedings 16, no. 2 (April 2003): 157–161, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201002/. Stella Fitzgibbons, “Liability Mistakes You Want To Avoid,” Today’s Hospitalist, November 2009, https://todayshospitalist.com/Liability-mistakes-you-want-to-avoid/. The information provided in this article offers risk management strategies and resource links. Guidance and recommendations contained in this article are not intended to determine the standard of care but are provided as risk management advice only. The ultimate judgment regarding the propriety of any method of care must be made by the healthcare professional. The information does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about this topic should be directed to an attorney. Comments are closed.
