Variation in printed handoff documents: Results and recommendations from a multicenter needs assessment

Area of Science:

• Medical error reduction
• Patient safety
• Healthcare quality improvement

Background:

• Patient care handoffs are a primary source of medical errors.
• Standardized verbal handoff techniques exist, but printed handoff document standardization lacks research.
• Variability in printed handoff documents can lead to miscommunications.

Purpose of the Study:

• To assess content variability in printed patient handoff documents.
• To identify essential data elements for standardized printed handoffs.
• To improve patient safety during care transitions.

Main Methods:

• Review of handoff documents from 9 pediatric hospitalist services.
• Structured group interviews to determine institutional priorities for written handoffs.
• Expert panel consensus on essential and recommended data elements for printed handoffs.

Main Results:

• Substantial variation in structure and content of printed handoff documents was found.
• Only 17% of potential data elements were uniformly present across all institutions.
• Essential elements include illness severity, patient summary, action items, and identifiers.

Conclusions:

• Wide variation in printed handoff document content necessitates standardization.
• Standardization can decrease data omissions during patient care transitions.
• Standardized printed handoffs have the potential to reduce downstream medical errors.