Miscommunication between healthcare providers during patient handoffs is a significant source of hospital medical errors, but adopting standardized communication procedures during this crucial time may help.

Amy J. Starmer, MD, MPH, of Boston Children’s Hospital and colleagues created a three-part structured handoff system and examined error rates pre-and post-intervention among 1,255 patient admissions and 84 physicians. 

The study included a total of 642 admissions before the intervention and 613 after the intervention, and took place between 2009 and 2010. The results were first published online in the Journal of the American Medical Association.

Continue Reading

The new system included a two-hour communication training session and interactive discussion regarding best practices for verbal and written handoffs. A mnemonic was then provided to help clinicians remember and standardize verbal handoffs.

Finally, the handoff process was restructured so that it took place in a private quiet space, was overseen by a chief resident or attending physician (at least once per resident per month) and became a team process that integrated interns and senior residents. In one hospital unit, a computerized handoff tool integrated into the electronic health record was also integrated.

Medical errors decreased from 33.8 to 18.3 per 100 admissions, and preventable adverse events decreased from 3.3 to 1.5 per 100 admissions, the researchers found.

There were also fewer omissions of important handoff elements on printed documents, and clinicians spent a greater proportion of time at a patient’s bedside in a 24-hour period — 10.6% post-intervention vs. 8.3% pre-intervention.

The time it took to conduct a verbal handoff did not change, the researchers reported, but handoffs were more likely to take place in a quiet and private location after the new system was implemented. There was no adverse impact on resident workflow.

“Given the increasing frequency of handoffs in hospitals following resident work-hour reductions and the high frequency with which miscommunications lead to serious medical errors, disseminating high-quality handoff improvement programs has the potential for benefit,” the researchers concluded. “Further work to improve and standardize handoffs across specialties and settings may lead to improvement in the safety of patients in teaching hospitals nationwide.”


  1. Starmer AJ et al. JAMA. 2013; 310(21):2262-2270.