Teaming & Handoffs

When Handoff Communications Fall through the Gaps, Everyone Gets Hurt

Patient handoffs – the process of exchanging critical patient information between clinicians – have the potential to introduce life-threatening errors if communication isn’t adequate.

Handoffs have long been identified as a high-risk but necessary activity in healthcare. A 2012 Joint Commission study recognized that ineffective hand-off communication is a critical patient safety problem, contributing to 80% of serious medical errors. In addition to causing patient harm, ineffective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.

Due to regulated duty hours and shift patterns in healthcare, patient handoffs are a frequent occurrence. It’s estimated that patient-care responsibility might transition between two or more physicians two or three times in 24 hours, and a typical teaching hospital might see 4,000 handoffs daily. Meanwhile, nurses change shifts every eight to 12 hours.

Why Are Patient Handoffs Such a Weak Link in Healthcare?

(Hint: Communication Failures)

When the exchange of key patient information that needs to happen between providers at a shift change is compromised somehow a defective handoff can result. Unfortunately, several things can get in the way of effective handoff communication…

Human Factors / Healthcare Environment. People can remember only 3-5 new pieces of information at a time for a limited amount of time.  Some people are visual learners others, some auditory and still others are experiential. Human factors play an important role in how well we communicate – along with things out of our control such as hospital settings where it can be noisy, stressful, and full of interruptions. It’s not surprising then, that studies show we only communicate 60% of what we think we have communicated to a colleague. 

Paper Workflows. Here’s a well-kept secret: Even with the most modern, up to date and integrated electronic health record (EHR), clinicians still rely on paper to scribble down patient symptoms, to-do lists, events from the day – all kinds of crucial information needed at handoff time: information that all too often is misplaced or not readily accessible in time-sensitive clinical situations.  

The EHR: A Library with a Card Catalog. That’s what navigating the EHR is like for care providers when it comes to retrieving critical patient handoff information. Sorting through disorganized data is cumbersome and time-consuming. 

Handwritten clinical notes

Inefficient Documentation Practices. Due to cumbersome documentation requirements, clinicians are forced to double and triple document information between progress notes, handoffs, problem lists and more. This often leads to the handoff not getting adequately updated. In fact, in a 2017 Sentinel Event Alert, the Joint Commission identified inadequate, incomplete or nonexistent documentation as a major cause of handoff communication failures. 

Among other factors, the Sentinel Event Alert found that these issues also increased the risk of communication failures at hand-off time: 

  • Insufficient or misleading information 
  • Ineffective communication methods 
  • Lack of time
  • Lack of standardized procedures

Bad Handoffs Lead to Errors, Patient Harm, and Malpractice Lawsuits

Patient Safety Risks

Communication gaps that happen during patient handoffs invite clinical error and threaten patient safety. Failed handoffs contribute to serious adverse events like medication errors and wrong-site surgery. Even consequences that may not necessarily be life-threatening can reduce the overall quality of care and negatively impact patient satisfaction.


According to a malpractice risk benchmark report by CRICO, 37% of all high-severity patient injury cases, including patient death, involved a failure in communication during provision of care. Additionally, communication failures in U.S. hospitals are estimated to have caused or contributed to 1,744 deaths and $1.7 billion in malpractice costs over a five-year period.

Good Handoffs: Happier Patients, Happier Clinicians

So here’s the $1.7 billion question: How can we bullet-proof patient handoffs? There are copious guidelines and recommendations available from patient safety leaders and industry groups –such as I-PASS.

In essence, effective handoffs depend on:

  • The ability of the sending clinician to provide relevant, updated information
  • The ability of the receiving clinician to easily understand and access that information for the provision of efficient, timely and safe care.

Processes like I-PASS and SBAR help, but they are only acronynwithout team collaboration, and supportive software, they don’t solve the need for truly standardized handoff procedures.

The Role of Technology in Improving Handoff Communication

Healthcare facilities should address handoff risks partially by providing technology that integrates with the EHR to enhance communication between sending and receiving clinicians, advises the Joint Commission.

The thing is, patient care is a team effort. But hospitals haven’t caught up yet with providing tools that foster effective communication and collaborative workflows. Implementing a good handoff process that addresses miscommunications stemming from paper workflows requires technology to do the heavy lifting.

Strengthen Handoffs with a Collaborative Tool

Handoffs, along with rounding and documentation, are all part of one overall clinical workflow. However disparate processes and tools have divided this workflow into separate steps, systems and procedures.

CareAlign is team-based technology that brings all these separate processes into one digital workflow. It eliminates paper workflows, providing a collaborative workspace where clinicians can manage their entire patient workload from one mobile device. It was designed to support standardization and streamlined communication.

Here are some of the specific ways that using CareAlign ensures effective patient handoffs:

Eliminate paper workflows. A web-based application built for dynamic, interdisciplinary workflows, CareAlign gives users easy access to handoffs, as well as EHRs, progress notes, rounding lists, and discharge summaries. It also fulfills ACGME handoff requirements.

Enable collaborative communication. The tool functions as a think space where clinicians can capture thoughts and collaborate with team members through sharable, patient-centered to-do lists and multi-user editing. This allows real-time updates from colleagues and reduces the risk of communication errors during handoffs.

Streamline, declutter, and save time. CareAlign allows easy archiving of information, avoiding inclusion of irrelevant notes. It also flags information from notes taken as a handoff item, which then shows up in the handoff document. This eliminates duplication of data entry – and saves time spent on administrative tasks.

Empower better decision-making. With more complete, updated information, clinicians can make on-point treatment decisions confidently and also have at-a-glance access to previous clinicians’ rationale and intent for earlier care decisions, which provides valuable context.

CareAlign Patient Wiki

CareAlign Solutions

CareAlign was built for clinicians, by clinicians with the goal of giving providers a tool that fits their workflows. We believe that clinical technology built with a focus on usability and accessibility improve patient safety and clinician wellness. Check out a quick, 5 minute demo fo CareAlign to see how it supports clinical workflows to improve patient care.

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