to another for the purpose of ensuring the continuity
and safety of the patient/client/resident’s care.”5
The Joint Commission has reviewed data from
4977 sentinel events that occurred between 1995
and March 31, 2008.6 In organizations accredited
by the Joint Commission, communication problems
have been identified as one of the contributing
causes in more than 60% of the sentinel events
reviewed. As a result, the Joint Commission created
a new National Patient Safety Goal in 2006: 2E
“Implement a standardized approach to ‘hand off’
communications, including an opportunity to ask
and respond to questions.”7 This goal has remained
unchanged and was repeated in 20078 and 2008.9
In 2005, the average length of stay for all
hospitalized patients was 4.8 days.10 Assuming that
patient care transfers occur between physicians at
least twice per day and between nurses at least 3
times per day, the average patient will be handed off
a minimum of 24 times per admission. This
represents 24 opportunities for inadequate
communication, each of which could result in reduced
patient safety and increased medical errors.
Mnemonics are commonly used to enhance
memory. In the case of handoffs, mnemonics may
increase memory of important steps and provide a
structured process to follow. Our experiences lead
us to believe that many hospitals have responded
to the Joint Commission handoff requirement by
adding a mnemonic to their handoff protocol. The
purpose of the current study was to identify all
handoff mnemonics, describe their use, and
summarize outcomes data from studies using these
mnemonics.
METHODS