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Minimizing communication failures in patient handoffs

The task of transitioning patients from one hospital department to other departments has to be performed carefully to prevent error and to assure the continuity of good patient care. But these patient "handoffs" can often create communications challenges.

In an original article published on May 11 in the Journal of the American College of Radiology, researchers from the Department of Radiology at Montefiore Medical Center, and from other centers in New York City, noted there is an abundance of research regarding handoffs in medicine, surgery, and nursing, but information on handoffs is limited within the field of radiology. Their article is thus significant since it provides a fresh look at patient handoffs in radiology. The authors describe how they have adapted the Institute for Healthcare Improvement’s reliability science framework to apply them to radiology practices.

Handoffs in radiology occur each time there is a transfer of clinical information and a shift in decision-making responsibility. The aspiration is that such handoffs assure the continuity of care through each transition. The paper observes that the written radiology report is the handoff from radiology staff back to clinical staff. However, failures in communication of various low or intermediate diagnostic suspicious findings coupled with vague follow-up recommendations can be responsible for numerous cases of delayed or, unfortunately, even missed diagnosis.

The authors offered a particularly thorough analysis of the handoff process for those patients receiving interventional radiology (IR) treatments. From the pre-procedural planning through to handoffs from non-clinical to clinical staff, every step in coordination of the IR patient’s care was analyzed. They observed that intra-procedural communication among team members is another type of handoff that impacts the effectiveness of treatment interventions and the ability to respond to procedural complications. Post-procedure handoffs in the IR suite include reporting of procedural outcomes, complications, and management plans to clinical and nursing teams, which are essential for appropriate post-therapeutic management in both inpatient and outpatient settings.

The adaptive strategies offered by the authors to help minimize errors caused by failed and misunderstood communications should make this paper required reading for radiologists and radiology managers not only in hospital-based radiology settings, but in every setting where such patient handoffs occur. 

Nearly two-thirds of all sentinel events involve communication failures. Handoffs in particular are responsible for more than half of those errors, and the frequency of patient handoffs has increased by 40% since the introduction of national resident duty hour restrictions in 2003 by the ACGME. As a result, standardized handoff practices and competency in handoff communication skills were mandated by both The Joint Commission in 2006 and the ACGME in 2010. Despite these changes, as recently as 2017, The Joint Commission noted that handoffs are still a major cause of medical error and sentinel events.


health care & life sciences, diagnostic imaging, radiology