News Release

Moving toward a gold standard in patient handoff protocols

Peer-Reviewed Publication

Human Factors and Ergonomics Society

You're in the hospital under around-the-clock care for whatever it is that ails you. During any 24-hour period, your physicians and nursing staff will change shifts at least once. When those shift changes occur, those going off shift will need to hand over information about the status of your condition to incoming staff clearly and accurately, or something could go seriously wrong - and things do frequently go wrong. According to a 2012 report by the Joint Commission, "an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients."

The Joint Commission has called for standardization in how handoffs are conducted, regardless of the tools caregivers use - checklists, computerized sign-out systems, mnemonics, and so on. Establishing an unambiguous standard that results in positive outcomes for patients, caregivers, and organizations requires careful evaluation of the various protocols that have been developed and studied.

In their upcoming Human Factors meta-analysis conducted for that purpose, Joseph Keebler and colleagues from Embry-Riddle Aeronautical University, Wichita State University, and Children's Mercy Hospital in Kansas City, Missouri, sifted through thousands of published reports to arrive at a small set of field studies pointing to what makes a handoff protocol successful. The researchers found that protocols that include 12 or more pieces of information (e.g., allergies, chief complaint, current medications) resulted in more details being passed to caregivers coming on shift.

Analyzing about 30,000 participants over 100,000 measured data points, this meta-analysis is the first of its kind in regard to attempting to summarize the vast handoff literature. The researchers note that their meta-analysis "provides good evidence for the general benefit of using handoff protocols, regardless of setting or protocol type." Protocols go a long way toward removing subjectivity about what constitutes important details regard a patient's care, fostering a shared mental model among caregivers, and eliminating the need to rely on memory alone. Nevertheless, Keebler et al. found evidence that implementing handoff protocols can sometimes increase the time in transition between caregivers and/or result in the omission of information.


Media representatives may obtain a copy of the article on request: "Meta-Analyses of the Effects of Standardized handoff Protocols on Patient, Provider, and Organizational Outcomes" by Joseph R. Keelber, Elizabeth H. Lazzara, Brady S. Patzer, Evan M. Palmer, Victoria Lew, Sara Fouquet, Y. Raymond Chan, and Robert Riss. Contact HFES Communications Director Lois Smith (310/394-1811,

The Human Factors and Ergonomics Society is the world's largest scientific association for human factors/ergonomics professionals, with more than 4,500 members globally. HFES members include psychologists and other scientists, designers, and engineers, all of whom have a common interest in designing systems and equipment to be safe and effective for the people who operate and maintain them. "Human Factors and Ergonomics: People-Friendly Design Through Science and Engineering."

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