Improving Safety at Hand-Off: A Resident-Led Project to Decrease Omissions & Increase Confidence

From the 2021 HVPAA National Conference

Hannah Goodwin (INOVA Children’s Hospital), Courtney Port, Chelsi Rose, Eugene Park, An Harmanli


With the 2003 ACGME mandate of duty hours came increased patient care hand-offs. Such transitions in care have been identified as high risk for medical errors and increased length of stay. Our local residency program adopted the IPASS tool to standardize shift hand-off structure, however, feedback from residents in 2019 revealed ongoing omissions of pertinent information and low receiver confidence in taking over patient care.


This project aimed to increase receiving resident confidence in being able to perform crucial patient care tasks after receiving hand-off by 20% and reduce the number of omissions per shift hand-off by 50% in 12 months by optimizing the EMR signout tool.


The Model for Improvement was utilized, testing changes for improvements to outcomes of interest via PDSA cycles. Measures include receiver comfort in performing patient care tasks following hand-off (outcome), the percentage of patient hand-offs with omissions (process), and the duration of hand-offs (balancing). We identified the most frequently missed categories of omissions during handoffs (Figure1). Mann-Whitney U Testing compared differences between groups over time. The resulting hand-off tool was piloted, adjusted based on results and feedback, and implemented.


The percentage of patient hand-offs with omissions reduced from 33% to 20% (p=0.03) in a single PDSA cycle (Figure2). An increase was also noted in the average confidence (3.2→ 3.9), in knowing their to-do list (3.7→4.3), and knowing what to do if something goes wrong (2.8→3.5). However, these differences were not significant (p>.05). The increase in understanding the overall direction/goal of care for the patient (2.7→3.8, p=.01) was significant (Figure3). The new hand-off tool did not increase the duration of hand-offs.


Organizing individual patient information within hand-offs by system, streamlining data to reduce unnecessary text, auto populating data when possible, and the addition of a section for disposition goals led to a reduction in hand-off omissions and increase in understanding patient care goals. Project team members attribute the majority of this improvement to two major changes: a systems-based hand-off and a section for disposition goals.

Clinical Implications

The implications of our study directly impact patient safety. As residents practice more autologous decision making, it becomes critical that they have an understanding of the direction and goal of patient care. Similarly, as residents field phone calls from concerned families and staff, it is crucial that residents respond appropriately. The process of a systems-based hand-off challenges the delivering resident to think through all important pieces of patient care and standardize the delivery of information. Decreasing omissions during hand-offs and understanding the big picture of patient care is integral to appropriately evaluating and acting on new data, addressing parental questions that arise, preventing near misses, preventing direct harm, and improving patient safety. Previous studies show such improvements can lead to decreased length of stay and mortality.

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