The Medical Hand-Off: When to Beware

What is a hand-off? It’s when a patient transfers from one setting of care to another. Common examples include:
nursing home to hospital emergency room (and back again)
hospital to rehabilitation facility
hospital to hospice care

Thousands upon thousands of patient transfers occur every day. In fact, an article in the Wall Street Journal last week quoted the President of the organization that accredits hospitals and other health care facilities (The Joint Commission) as stating:

There are 4,000 hand-offs a day in a typical teaching hospital. If 90% go flawlessly, that’s still 400 failures per day.

The Joint Commission collaborated with 10 hospitals and systems that volunteered to participate in a project led by the Commission and found that transfers were defective 37% of the time. So if I do the math here, a teaching hospital that has 4,000 hand-offs a DAY would be within the average to have 1480 flawed communications PER DAY when transferring care in to, or out of, the hospital setting. Houston, we have a problem! Within the Journal article is a link to the chart from the Commissions’ Report that documents the validated root causes for hand-off communication failures. There are 4 causes (out of 20) that were identified that jumped out at me. Three of the 4 were reported by 7 of the 10 participating hospitals:

Culture does not promote successful hand-off, e.g. lack of teamwork and respect
Expectations between sender and receiver differ
Sender, who has little knowledge of patient, is handing off patient to receiver

The 4th one was validated at every one of the 10 hospitals. These are not small, community facilities…they include Johns Hopkins, Mayo Clinic, NY Presbyterian, and Massachusetts General. The most common cause of hand-off failure was:

Sender provides inaccurate or incomplete information, e.g. medication list, DNR [Do Not Resuscitate], concerns/issues, contact information.

I cannot say this often enough. It is critical that patients have a trusted friend or family member building a file of the patient’s care history and reviewing that care history with every new facility or physician who cares for the patient. The good news is that organizations like The Joint Commission have started to take notice and recognize the dire need for quality controls. The bad news is that change takes time and while the incidence of medical errors will (hopefully) ultimately decrease significantly, the risk will never be totally eliminated.