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Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications
  1. I Philibert
  1. Dr I Philibert, Accreditation Council for Graduate Medical Education, 515 North State Street, Suite 2000, Chicago, IL 60654, USA; iphilibert{at}


Background: Limits on resident hours increase the frequency of patient hand-offs and may contribute to information transfer problems that contribute to adverse outcomes. This study analysed attributes that affect hand-off accuracy, including use of data summaries and end-of-shift transfer strategies from high-reliability organisations.

Method: Mixed-method study combining qualitative interviews and surveys of residents in internal medicine, surgery, paediatrics and ob-gynaecology.

Findings: Strategies in resident hand-offs mirrored the intent of end-off-shift transfers in high-reliability organisations, but approaches differed, reflecting the fluid nature of residents’ work and focusing on multiple patients with differing needs. Clinical skills were relevant to hand-off quality for both participants. Cross-coverage, more common duty hour limits, had a negative effect on hand-off accuracy. It significantly increased the likelihood of unplanned changes in care and errors attributed to the hand-off. For surgery residents, asynchronous hand-offs without true interactions increased. Data summaries contributed to efficiency, but were associated with greater incidence of surprises and errors, even when they did not replace verbal hand-offs. Third parties, particularly nursing, functioned as redundant systems that prevented or trapped many hand-off errors.

Conclusions: Hand-offs depended on residents’ clinical skills, suggesting a need for education and supervision of junior residents’ transfers. Research is needed to explore how to conduct effective hand-offs under shortened duty periods. This should assess how transfer strategies and data summaries could enhance efficiency and effectiveness, and how they could substitute when a verbal interactive hand-off is not feasible.

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  • Competing interests: IP is employed by the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programmes and sets standards for resident hours in the United States. The findings and conclusions are solely those of the author and do not represent the views of the ACGME.

  • Ethics approval: Ethics approval was provided by University of Iowa Institutional Review Board (IRB) and Henry Ford Health System IRB.

  • Patient consent: Obtained.

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