A Limited Intervention to Improve the Quality of Physician Handoffs by Service Type in an Academic Medical Center

1Georgetown University Hospital, Washington, DC
2Georgetown University Hospital, Washington, DC
3University of Maryland Medical Center, Baltimore, MD
4Georgetown University Hospital, Washington, DC
5Georgetown University Hospital, Washington, DC
6Georgetown University Hospital, Washington, DC
7Georgetown University, Washington, DC
8Georgetown University, Washington, DC
9Georgetown University, Washington, DC
10Georgetown University, Washington, DC
11Georgetown University School of Nursing and Health Studies, Washington, DC

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 66


Between 44,000 and 98,000 patients die as the result of medical errors annually. Suboptimal communication is the root cause of most sentinel events in hospitalized patients. Implementation of resident duty hours has resulted in increased frequency of patient handoffs. In turn, increased handoffs are associated with adverse patient safety events. Intensive intern training in optimal physician handoffs (involving 1 week of supervised handoffs) has been associated with improved perception of the quality of physician handoffs. Data on more limited interventions are lacking. Also, the quality of physician handoffs by provider type is not characterized yet.


The aim was to evaluate the impact of a 1‐hour lecture on the quality of physician handoffs among medicine and general surgery house staff at Georgetown University Hospital. This was a prospective pre‐/postintervention design. The intervention was a 1‐hour evidence‐based lecture on optimal physician handoffs presented to both medicine and surgery house staff at their monthly morbidity and mortality conference setting. Between June 2011 and January 2012, 478 written sign‐outs and 492 verbal sign‐outs of the medicine and surgery house staff were directly observed before and after the 1‐hour lecture. Handoffs were evaluated for the presence of accepted elements of optimal patient handoffs (i.e., patient identifiers, code status, anticipatory guidance, questions/read‐back). In addition, medication lists from written sign‐outs were compared with “gold standard” lists from clinical information systems. Medication errors per patient were quantified and characterized as omissions/additions and according to severity. A pre‐/postintervention analysis was carried out employing the chi‐square test for categorical data and the Student t test for linear data. Medication errors at baseline were also analyzed by provider service.


Following the intervention, presence of code status and patient location on written sign‐outs increased from 15% to 28% (P = 0.0008) and 73%–86% (P = 0.002), respectively. More complex verbal sign‐out elements such as “if–then” and “questions/read back” statements did not improve. At baseline, medicine house staff had significantly fewer average medication errors per patient than did their surgical counterparts (2.99 vs. 6.41; P < 0.0001). Mean medication errors per patient trended downward for both medicine and surgery patients but did not reach statistical significance.


Overall, the quality of both written and verbal sign‐out was suboptimal. Medication errors were common and more frequent on written surgical sign‐outs. A 1‐hour lecture modestly improved some written sign‐out elements, but had no effect on more complex verbal sign‐out elements and medication errors. More robust interventions are needed to improve physician handoff quality (i.e., computerized physician handoff tools and/or more intensive educational efforts) with a particular focus on engaging surgical providers.

To cite this abstract:

Montero A, Dzundza J, Wagner L, Kon R, Molineux M, Steiner J, Brown R, Esfahani K, Oh C, Fulton T, Kozonis G. A Limited Intervention to Improve the Quality of Physician Handoffs by Service Type in an Academic Medical Center. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 66. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-limited-intervention-to-improve-the-quality-of-physician-handoffs-by-service-type-in-an-academic-medical-center/. Accessed July 23, 2019.

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