An Overlooked but Dangerous Handoff… of One Million Patients at a Time

A quick heads up on an article written by a very talented UCSF psychiatrist named John Young, which I had the opportunity to co-author. John observed that, despite all the recent literature about handoffs (such as here and here), no one has given much thought to the Mother of all Handoffs: the transition of outpatient panels from graduating residents to brand new interns that happens around July 1st every year.

In the article, in this week’s JAMA, we point out that the “year-end handoff” carries a number of additional risks above and beyond the usual threat of fumbles. For example,

  • Most handoffs involve two providers of comparable knowledge and experience. The year-end handoff involves a handoff from a seasoned expert (the graduating resident) to a novice (the brand new intern, who was a med student a week earlier);
  • The volume is huge: for an individual resident, the handoff may involve as many as 100-200 patients; for a clinic, often 1000-3000 patients; for the nation, about 1 million handoffs every year. It seems like a near-certainty that individuals and systems will be overwhelmed; 
  • Patients may lose trust or suffer other clinical or psychological deteriorations as they experience the loss of their long-time provider.

John and I argue that the year-end handoff requires a new approach, mostly drawn from emerging best practices for other types of handoffs, but with special attention to the unique features of this transition. Handoffs should be systematized, documentation should be standardized, person-to-person transitions (a face-to-face meeting if possible; a phone conference between outgoing and incoming resident if not) should be facilitated, and faculty mentorship should be robust. We also need research to characterize and quantify the hazards and to test new strategies.

Particularly for those of you in the training business, I hope this article helps stimulate your thinking about these handoffs – they are likely quite risky and it is time they received real attention.

2 Responses to “An Overlooked but Dangerous Handoff… of One Million Patients at a Time”

  1. menoalittle September 28, 2009 at 3:11 pm #

    Bob,

    Kudos for this report.

    At a time when flawed handoffs are gaining traction with patient safety organizations, continuity of care and cognitive contact with the same patients is being depreciated. There are complex and variable schedules, hospitalist care sans communication with the outside world, mega-multispecialty groups (a different day, a different attending), limited housestaff work hours;

    and last but not least, haphazard electronic storage of data written in legible gibberish that can not be found when it is needed (where’s Waldo?)

    I was told by our presidents and congress people that these problems will be solved with HIT.

    It is admirable that the patient safety mavens desire to fix the unintended consequences of the programs they and their safety predecessors blindly enacted.

    Best regards,

    Menoalittle

  2. cuizonbernardo March 10, 2010 at 9:56 am #

    I Love this article

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