Avoiding Malpractice Risks in the Patient Handoff

Mark E. Crane


May 10, 2010

In This Article


"Achilles' heel" and "time bomb" are metaphors used to describe the handoff, that transition when patients are transferred from one doctor to another, or from an outpatient setting to a hospital or nursing home.

Problems with handoff communication are listed as one of the root causes in up to 70% of adverse sentinel events compiled by the Joint Commission. The potential for something to go wrong -- needed follow-up care that slips through the cracks or vital information that isn't communicated in a timely fashion -- can have life or death impact for patients. It's also a leading driver of malpractice lawsuits against health professionals.

In recent years, handoffs have become more troubling because of the growth in the number of hospitalists -- physicians with no prior relationship to the patient. Just 10 years ago, there were about 3500 physicians describing themselves as hospitalists. Now, there are almost 30,000 practicing in about half of the nation's community hospitals, according to the Society of Hospital Medicine.

Who is ultimately found liable for fumbling the patient handoff may be up to a jury to decide years after the event. Count on plaintiffs' attorneys suing everyone involved in the patients' care – at least initially -- regardless of their degree of accountability.

The data on lawsuits against hospitalists are sparse because these programs only formally began in 1996, but liability insurers fear that lawsuits due to miscommunication could grow rapidly. That's why they're focusing more attention than ever on studying the anatomy of the handoff and how to thwart mishaps.

Handoffs are nothing new. Every time a physician goes on vacation or gets sick, it's his or her responsibility to make sure that the covering physician is up to speed on the patients' needs. Every referral to a specialist carries the same responsibility.

As part of its patient safety goals, the Joint Commission in 2006 added a requirement that hospitals seeking accreditation standardize their approaches to handoff communication.

The need couldn't be clearer. Numerous studies have shown all sides in the handoff routinely drop the ball and fail to relay timely crucial information to colleagues. What constitutes an effective handoff is rarely taught in medical school. A 2005 study in Academic Medicine found that only 8% of schools talk about handoffs in a formal didactic session.


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