Patient Handoffs and Trainee Perspectives Across an Institution: A Mixed Methods Study Informing Best Practices and an Expanded Conceptual Framework for Handoffs

Background: Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed best practices for both training programs and institutions. Methods: : Using a constructivist paradigm, the authors conducted an explanatory-sequential mixed method study to investigate trainees’ experiences with patient handoffs across Stanford Health Care, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. Results: : 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: 1) handoff elements, 2) health-systems-level factors, 3) impact of the handoff, 4) agency (duty), and 5) blame and shame. Conclusions: : Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of best practices that training programs and sponsoring institutions should implement to protect patient safety. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.