Evidence-Based Practice lmplications-Handoffs for
Today's Health Care Environment
The Australian Council for Safety and Quality in Health Care evaluated 777 papers for possible
inclusion in a literature review on handoffs. 1A total of 27 papers met the inclusion criteria, but
it was reported that ''no best practice" (p. 2) existed related to systems emerged in
the search--although a number of recommendations were provided for systems, organizational, and
individual factors.1 Handoffs are an extremely complex phenomenon to study as they occur in a
variety of settings; stages along the continuum of care; and among various personnel with different
skill sets, priorities, and educational levels.
Contributors to handoffproblems included failed communication ,4 5• 6 7 10 31 omissions,31 64
108
1 33 73
• • • • • •
108 distractions,
lack of or illegible documentation/ • •
lack of utilization of transfer
forms,69 incomplete medical records,64 lack of medication reconciliation, 129 130 and lack of easy
accessibilif{' to information.6
33 73
•
A variety of environmental issues emerged-including
designs28 5 -that served to increase, rather than decrease, the number ofhandoffs. Interfacility
handoffs posed a number of challenges, including cultural differences73 and lack of integrated
systems, thereby increasing the likelihood of transmission difficulties between organizations.
Organizational and system failures or lack of systems to support the handoff process emerged as
contributors to adverse events.4 6 7 10 A lack of knowledge was found regardin effective handoff
117
• • •
3 1 7
processes,
and education on effective handoff strategies was also lacking. •
Handoff
processes need to include consideration of the person involved in the handoff and their level of
education, expertise, and comprehension (e.g., the novice nurse's informational needs may be
different from the expert nurse).41 Novices also differ from expert nurses in their use of
information.84
There must be an organizational commitment to the development and implementation of systems that
support effective handoffs as well as a just culture.133 134 This includes cultures of safety and
learning. 134 A safety culture su,pports identifications of problems and errors to be
addressed to prevent the recurrence.13
13 A culture of learning promotes learning from the
experiences of the past to prevent a recurrence of tragic fumbled handoffs. Environments and
processes need to be designed to promote desired outcomes76 and enhance patient safety.137