Getting the Handoff Right

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I attended the 6th Annual Medical Education Celebration on November 17, 2011 and saw many interesting posters. One of them by Dr. Aparna Kamath caught my eye; it was about how to improve the handoff process between resident physicians. I mentioned the handoff in a recent post, “Back When I Never Got to Sleep”, which you can read at short link The critical issue is creating the safest possible medical care for patients now that duty hours have been shortened for trainees, which has led to a sort of shift work approach leading to the need to clearly communicate to the doctor coming on shift what the jugular issues are with respect to providing high-quality medical care in hospitalized patients.

Dr. Kamath, Assistant Professor of internal medicine here at The University of Iowa Hospitals and Clinics and her colleagues developed a standardized tool for handoffs which includes a very specific safety check list for use on internal medicine wards. It’s not hard to see how this could be adapted for psychiatric residents as well. The tool is called the HAND-IN-OUT verbal communication tool and SAFE checklist.

Have a look at excerpts from the poster above in the slide show. I especially like the HAND-IN-OUT mnemonic:

H – History including sick or DNR, assessment,

general course, recent changes or new events.

A – Anticipated events.

N – Necessary acts for tonight with contingency


D – Doubts.

I – Interpretation/ Iteration.

N – Notes to be documented in chart or handoff.

O – Overnight.

U – Unanticipated events.

T – Things done.

And the SAFE mnemonic (“Is my patient SAFE tonight?”) is especially well-done, including the mental status to check for delirium:

S: Social issues

Family concerns addressed

Nursing concerns addressed

A: Aids and Access




IV lines

Fever/ BP

Recurring needs previous


Other needs?

F: Falls and Food

Confirm activity

Mental status


E: Elimination issues

Nausea/ Vomiting

Diarrhea/ Constipation


And don’t just take my word for it; listen to Dr. Kamath herself:

Handoffs between healthcare providers are critical transition points in the care of a hospitalized patient. Nurses change shifts every 8 to 12 hours and resident work hour restrictions lead to frequent patient hand offs creating opportunities for errors. Accurate and timely transfer of patient care information is vital to keep patients safe across shifts. Hence we decided to establish a handoff workshop for our internal medicine residents at UIHC. The main objective of this workshop is to teach residents to be effective and efficient in handoff communication. However before designing this curriculum, we thought it was imperative to assess residents perceived needs for the handoff training. We did this by informal emails to the residents, formal surveys, observing resident handoffs, and performing a flow map of the handoff process.  The results of the need assessment informed the handoff workshop which consists of simulation scenarios, simulation exercises, and didactic sessions. We also created a standardized verbal communication tool (mnemonic HAND-IN-OUT) and a SAFE checklist for common overnight events.

This could be the free and open-access alternative to the hand-off tool offered at link Great job, Dr. Kamath!

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