How to Avoid Fumbled Handoffs When Discharging Patients

Janice Simmons, for HealthLeaders Media , August 13, 2009

"We found that a huge number—72%- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up," said Martin Were, MD, a Regenstrief Institute investigator and an assistant professor of medicine at the Indiana University School of Medicine.

"In the patient safety arena, this is what you call a 'fumbled handoff'—and it leads to medical errors," Were added. The study puts the spotlight on the need to improve "how information is communicated to the outpatient follow up providers."

And it's not only test data that patients should be aware of. In my recent HealthLeaders magazine article on reducing hospital readmissions, I spoke with Brian Jack, MD, associate professor and vice chair of the department of family medicine at Boston Medical Center, who was behind the development of Project RED (which stand for "reengineered discharge").

Project RED lists 11 points to talk about with patients before discharge—including discussing with the patient "any tests or studies that have been completed in the hospital and . . . who will be responsible for following up the results."

"What we did basically was to collect information in the hospital that was relevant to people that allowed them to take care of themselves when they went home," Jack said. In other words, it let them be prepared—avoiding the fumbled handoff that could end them back soon in the hospital.

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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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