Click the arrow in the image above to view Best Practices and compare the problems below with their solutions. 

1. PROBLEM: Lack of attention
The physician on the left—who clearly has been on duty or on call all night—is attempting to convey information about his patients to the incoming providers. However, the incoming physician appears unengaged and is unhappily scanning the notes in her hand, and has a wireless earbud in her ear. The nurse on the right is concentrating on drinking his coffee and seems to be paying no attention to the hand-off at all. Moreover, the team members’ focus is not enhanced by the fact that they are choosing to conduct a hand-off in a chaotic, noisy environment.
Patient hand-offs should be carried out in a quiet, distraction-free zone where incoming and outgoing providers can focus on the effective and accurate transfer of patient information and strategies. Everyone involved should be attentive and engaged to ensure that all information is correct, nothing is missed, and the patient has an opportunity to ask questions if needed.
2. PROBLEM: Unprofessionalism
Both the outgoing and incoming providers are showing some degree of unprofessionalism. The outgoing physician appears disheveled, the outgoing nurse is blowing bubblegum, the incoming doctor has an earbud in her ear, and the incoming nurse is slurping his coffee.
Providers conducting a patient hand-off should make every effort to ensure that they appear and act in a professional and responsible manner. Their personal appearance should be neat and tidy; no one should be eating, drinking or chewing gum; and they should give their full attention to the information exchange.
3. PROBLEM: Privacy breaches
Conducting a patient hand-off in a noisy environment such as in front of the nursing station can lead not only to an ineffective and inaccurate transfer of patient information but also to HIPAA violations. In this scenario, the conversation can potentially be overheard by other staff members as well as by visitors (like the red-haired woman in the green shirt) and patients (like the elderly woman on the left).
To prevent or resolve any privacy issues, providers should choose a quiet and private hand-off location where no patient information can be overheard. Ideally, providers should aim for a “warm hand-off” at the patient’s bedside so that the patient has an opportunity to contribute to the conversation and ask any questions that they may have for the providers about past care or next steps.
4. PROBLEM: Quality of Care Issues
Because several of the providers are not paying strict attention to the hand-off process in this scenario and have no way to document any patient information that is being provided, it is very possible that the quality of care will suffer. The incoming providers may overlook concerning patient symptoms or trends, possibly leading to a failure to diagnose the patient correctly or to provide appropriate care.
Instead of handing over potentially indecipherable handwritten notes to the incoming providers, outgoing providers should ensure that all necessary and relevant information is recorded in the patient’s medical record before they end their shifts. Incoming providers should take notes electronically during the hand-off, if possible, to ensure that they and any co-managing providers are fully aware of any concerning medical issues, the plan of care, and potential problems to watch for during the upcoming shift.
5. PROBLEM: Lack of documentation
In this scenario, no one is taking notes or otherwise documenting the conversation. This could lead to the omission of critical details or the inclusion of inaccurate information—especially if providers wait to document the information that was conveyed until after the hand-off, or fail to document it at all. An hours-long delay in documentation caused by a hectic clinical schedule could make it more difficult for providers to remember exact details and could lead to questions about the chart’s accuracy if there is a poor outcome and a malpractice case ensues.
Providers should clearly and accurately document information provided during the hand-off in the EHR. This ensures that it will be available for their own later reference and for the reference of co-managing providers. In addition to recording details related to the patient’s clinical status, providers should document any questions the patient may have had, and the answers provided to those questions. A complete record of the hand-off, entered in the medical record at the time of the hand-off, can help to keep the patient healthy and safe, and ensure that incoming providers have a complete picture of the patient’s history and any potential clinical concerns.
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