Fumbling Handoffs Can Cost You The Game… And They Can Be Avoided

A Solid Handoff Play Scores Big In Patient Flow

By Justin Allen

Once a patient enters a hospital for acute care, a multitude of patient handoffs occur. This creates multiple opportunities where two or more caregivers are required to communicate to ensure that patients’ progression stays on track and their care is optimized. Any slight breakdown in communication within these handoffs could unintentionally cause major complications. A study released in 2016 estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years. (1)

Good communication in the hospital is just like good communication on the football field.  The quarterback calls a play to the offensive line.  If there is a breakdown, the receiver may miss the pass and the defense may intercept the ball. This is no different from hospitals: nurses giving effective report for ED Admissions, patient unit transfers, critical care transports, providing medication, etc. However, since hospitals are very complex systems it compounds the problem exponentially. It’s estimated that a typical teaching hospital may experience more than 4,000 hand-offs every day. (2)


In order to ensure you don’t fumble your handoffs and maximize the success of the high number of handoffs that happen daily, let’s look at three key areas of focus that could help your organization stay on track:



It is important to map out your current state in order to get to your future state that includes better handoffs.  They key here is to understand the root cause analysis, or you may end up focusing on the wrong things.  In order to get there:

  • Leadership owns patient handoff problems and have the commitment to invest in resources and time to address inefficiencies.

  • Safety & Quality should be organizational priorities for any provider of care. Re-examine amongst care teams how patient handoffs are not meeting expected outcomes.



Communication errors occur when things are done differently on each unit.  Chaos can lead to mistakes.  Try these first:

  • Standardize what good looks like during handoffs "protocols, checklist, using mnemonics (I-PASS)".

  • Monitor performance over time to ensure culture and standardization aren't deviating from what is expected.



Being proactive can help ensure smooth transitions.  If a patient is being discharged later today and is going home with equipment, transport can arrange a ride home for that patient and delays can be avoided with proper and timely communication.  Two ways to start:

  • Set organizational goals to help the care team to be proactive rather than reactive. If staff can anticipate specific progression goals, then they will be better prepared to prioritize what is needed for the handoff in a timely manner.

  • Leverage existing technology and visual management tools to communicate information real time. This will help enforce standards, bring focus to irregularities, and share information with others.

These are just a few areas of focus that can help put your organization on track to properly handle the thousands of handoffs in a day. Don’t be overwhelmed by the number, because you now have tools to share with your staff and decision makers. And remember, strong communication can lead to a winning record for your team!



  1. CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).

  2. Vidyarthi AR. Triple handoff. AHRQ Web M&M, September 2006.