Handoffs in Hospitals: Research for the Design of Better Practices

Award Year:
Michael Cohen
Patient Safety
Despite significant attention and activity by U.S. hospitals, medical errors continue to pose serious challenges to patient safety. Among the many aspects of patient care where problems can arise, from lethal medication errors to wrong-site surgery, a routine process that occurs several times a day in hospitals can also endanger patients. That process, known as a "handoff", refers to the brief transfer between health professionals of information, control and responsibility for a patient that occurs whenever shifts change on a nursing unit or when a patient is moved within the hospital - from the operating room to intensive care, for example. Dr. Michael D. Cohen sought to more fully understand the process and risks of handoffs, the role they play in staff learning, and the potential they hold for improving the quality of hospital care. His project, Handoffs in Hospitals, Research for the Design of Better Practices, helped inform efforts to redesign handoffs in ways that better protect patients and enhance high-quality care.