Variation in printed handoff documents

Results and recommendations from a multicenter needs assessment

Glenn Rosenbluth, James F. Bale, Amy J. Starmer, Nancy D. Spector, Rajendu Srivastava, Daniel C. West, Theodore C. Sectish, Christopher P. Landrigan, Elizabeth L. Noble, Lisa L. Tse, Jennifer K. O'Toole, Maitreya Coffey, Lauren A. Destino, Jennifer L. Everhart, Shilpa J. Patel, Jennifer H. Hepps, Joseph O. Lopreiato, Clifton E. Yu, F. Sessions Cole, Sharon Calaman & 36 others Madelyn D. Kahana, Robert S. McGregor, John S. Webster, April D. Allen, Angela M. Feraco, Anuj K. Dalal, Carol A. Keohane, Stuart Lipsitz, Jeffrey M. Rothschild, Matt F. Wien, Catherine S. Yoon, Katherine R. Zigmont, Javier Gonzalez del Rey, Lauren G. Solan, Megan E. Aylor, Tamara Wagner, Zia Bismilla, Sanjay Mahant, Rebecca L. Blankenburg, Madelyn Kahana, Jaime Blank Spackman, Adam Stevenson, Kevin Barton, Kathleen Berchelmann, F. Sessions Cole, Christine Hrach, Kyle S. Schultz, Michael P. Turmelle, Andrew J. White, Bronwyn D. Carlson, Vahideh Nilforoshan, Dorene Balmer, Carol L. Carraccio, David McDonald, Alan Schwartz, Karen M. Wilson

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

BACKGROUND: Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. OBJECTIVE: To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. SETTING: Pediatric hospitalist services at 9 institutions in the United States and Canada. METHODS: Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. RESULTS: Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. CONCLUSIONS: Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

Original languageEnglish (US)
Pages (from-to)517-524
Number of pages8
JournalJournal of Hospital Medicine
Volume10
Issue number8
DOIs
StatePublished - Aug 1 2015

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Needs Assessment
Patient Transfer
Medical Errors
Interviews
Patient Care
Hospitalists
Patient Admission
Canada
Consensus
Hypersensitivity
Pediatrics
Weights and Measures

ASJC Scopus subject areas

  • Health Policy
  • Assessment and Diagnosis
  • Care Planning
  • Fundamentals and skills
  • Leadership and Management

Cite this

Rosenbluth, G., Bale, J. F., Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., ... Wilson, K. M. (2015). Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment. Journal of Hospital Medicine, 10(8), 517-524. https://doi.org/10.1002/jhm.2380

Variation in printed handoff documents : Results and recommendations from a multicenter needs assessment. / Rosenbluth, Glenn; Bale, James F.; Starmer, Amy J.; Spector, Nancy D.; Srivastava, Rajendu; West, Daniel C.; Sectish, Theodore C.; Landrigan, Christopher P.; Noble, Elizabeth L.; Tse, Lisa L.; O'Toole, Jennifer K.; Coffey, Maitreya; Destino, Lauren A.; Everhart, Jennifer L.; Patel, Shilpa J.; Hepps, Jennifer H.; Lopreiato, Joseph O.; Yu, Clifton E.; Sessions Cole, F.; Calaman, Sharon; Kahana, Madelyn D.; McGregor, Robert S.; Webster, John S.; Allen, April D.; Feraco, Angela M.; Dalal, Anuj K.; Keohane, Carol A.; Lipsitz, Stuart; Rothschild, Jeffrey M.; Wien, Matt F.; Yoon, Catherine S.; Zigmont, Katherine R.; Gonzalez del Rey, Javier; Solan, Lauren G.; Aylor, Megan E.; Wagner, Tamara; Bismilla, Zia; Mahant, Sanjay; Blankenburg, Rebecca L.; Kahana, Madelyn; Spackman, Jaime Blank; Stevenson, Adam; Barton, Kevin; Berchelmann, Kathleen; Sessions Cole, F.; Hrach, Christine; Schultz, Kyle S.; Turmelle, Michael P.; White, Andrew J.; Carlson, Bronwyn D.; Nilforoshan, Vahideh; Balmer, Dorene; Carraccio, Carol L.; McDonald, David; Schwartz, Alan; Wilson, Karen M.

In: Journal of Hospital Medicine, Vol. 10, No. 8, 01.08.2015, p. 517-524.

Research output: Contribution to journalArticle

Rosenbluth, G, Bale, JF, Starmer, AJ, Spector, ND, Srivastava, R, West, DC, Sectish, TC, Landrigan, CP, Noble, EL, Tse, LL, O'Toole, JK, Coffey, M, Destino, LA, Everhart, JL, Patel, SJ, Hepps, JH, Lopreiato, JO, Yu, CE, Sessions Cole, F, Calaman, S, Kahana, MD, McGregor, RS, Webster, JS, Allen, AD, Feraco, AM, Dalal, AK, Keohane, CA, Lipsitz, S, Rothschild, JM, Wien, MF, Yoon, CS, Zigmont, KR, Gonzalez del Rey, J, Solan, LG, Aylor, ME, Wagner, T, Bismilla, Z, Mahant, S, Blankenburg, RL, Kahana, M, Spackman, JB, Stevenson, A, Barton, K, Berchelmann, K, Sessions Cole, F, Hrach, C, Schultz, KS, Turmelle, MP, White, AJ, Carlson, BD, Nilforoshan, V, Balmer, D, Carraccio, CL, McDonald, D, Schwartz, A & Wilson, KM 2015, 'Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment', Journal of Hospital Medicine, vol. 10, no. 8, pp. 517-524. https://doi.org/10.1002/jhm.2380
Rosenbluth, Glenn ; Bale, James F. ; Starmer, Amy J. ; Spector, Nancy D. ; Srivastava, Rajendu ; West, Daniel C. ; Sectish, Theodore C. ; Landrigan, Christopher P. ; Noble, Elizabeth L. ; Tse, Lisa L. ; O'Toole, Jennifer K. ; Coffey, Maitreya ; Destino, Lauren A. ; Everhart, Jennifer L. ; Patel, Shilpa J. ; Hepps, Jennifer H. ; Lopreiato, Joseph O. ; Yu, Clifton E. ; Sessions Cole, F. ; Calaman, Sharon ; Kahana, Madelyn D. ; McGregor, Robert S. ; Webster, John S. ; Allen, April D. ; Feraco, Angela M. ; Dalal, Anuj K. ; Keohane, Carol A. ; Lipsitz, Stuart ; Rothschild, Jeffrey M. ; Wien, Matt F. ; Yoon, Catherine S. ; Zigmont, Katherine R. ; Gonzalez del Rey, Javier ; Solan, Lauren G. ; Aylor, Megan E. ; Wagner, Tamara ; Bismilla, Zia ; Mahant, Sanjay ; Blankenburg, Rebecca L. ; Kahana, Madelyn ; Spackman, Jaime Blank ; Stevenson, Adam ; Barton, Kevin ; Berchelmann, Kathleen ; Sessions Cole, F. ; Hrach, Christine ; Schultz, Kyle S. ; Turmelle, Michael P. ; White, Andrew J. ; Carlson, Bronwyn D. ; Nilforoshan, Vahideh ; Balmer, Dorene ; Carraccio, Carol L. ; McDonald, David ; Schwartz, Alan ; Wilson, Karen M. / Variation in printed handoff documents : Results and recommendations from a multicenter needs assessment. In: Journal of Hospital Medicine. 2015 ; Vol. 10, No. 8. pp. 517-524.
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abstract = "BACKGROUND: Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. OBJECTIVE: To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. SETTING: Pediatric hospitalist services at 9 institutions in the United States and Canada. METHODS: Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. RESULTS: Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17{\%}) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. CONCLUSIONS: Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.",
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T1 - Variation in printed handoff documents

T2 - Results and recommendations from a multicenter needs assessment

AU - Rosenbluth, Glenn

AU - Bale, James F.

AU - Starmer, Amy J.

AU - Spector, Nancy D.

AU - Srivastava, Rajendu

AU - West, Daniel C.

AU - Sectish, Theodore C.

AU - Landrigan, Christopher P.

AU - Noble, Elizabeth L.

AU - Tse, Lisa L.

AU - O'Toole, Jennifer K.

AU - Coffey, Maitreya

AU - Destino, Lauren A.

AU - Everhart, Jennifer L.

AU - Patel, Shilpa J.

AU - Hepps, Jennifer H.

AU - Lopreiato, Joseph O.

AU - Yu, Clifton E.

AU - Sessions Cole, F.

AU - Calaman, Sharon

AU - Kahana, Madelyn D.

AU - McGregor, Robert S.

AU - Webster, John S.

AU - Allen, April D.

AU - Feraco, Angela M.

AU - Dalal, Anuj K.

AU - Keohane, Carol A.

AU - Lipsitz, Stuart

AU - Rothschild, Jeffrey M.

AU - Wien, Matt F.

AU - Yoon, Catherine S.

AU - Zigmont, Katherine R.

AU - Gonzalez del Rey, Javier

AU - Solan, Lauren G.

AU - Aylor, Megan E.

AU - Wagner, Tamara

AU - Bismilla, Zia

AU - Mahant, Sanjay

AU - Blankenburg, Rebecca L.

AU - Kahana, Madelyn

AU - Spackman, Jaime Blank

AU - Stevenson, Adam

AU - Barton, Kevin

AU - Berchelmann, Kathleen

AU - Sessions Cole, F.

AU - Hrach, Christine

AU - Schultz, Kyle S.

AU - Turmelle, Michael P.

AU - White, Andrew J.

AU - Carlson, Bronwyn D.

AU - Nilforoshan, Vahideh

AU - Balmer, Dorene

AU - Carraccio, Carol L.

AU - McDonald, David

AU - Schwartz, Alan

AU - Wilson, Karen M.

PY - 2015/8/1

Y1 - 2015/8/1

N2 - BACKGROUND: Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. OBJECTIVE: To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. SETTING: Pediatric hospitalist services at 9 institutions in the United States and Canada. METHODS: Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. RESULTS: Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. CONCLUSIONS: Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

AB - BACKGROUND: Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking. OBJECTIVE: To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. SETTING: Pediatric hospitalist services at 9 institutions in the United States and Canada. METHODS: Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices. RESULTS: Nine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended. CONCLUSIONS: Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

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