Given this degree of risk, considerable attention has been focused on interventions to improve patient safety and reduce errors during these transfers (18, 19), many of which have been adapted from industries such as nuclear power and space aviation in which transition errors have high consequences (20). These interventions can be organized into four categories: content, infrastructure, communication processes, and organizational culture. Table 1 summarizes the recommended practices from the existing literature in each of these categories.
The purpose of any handoff is to establish a shared mental model about a patient in order to avoid unwarranted changes in goals, decisions, priorities, or plans. For all settings, a safe handoff includes the following features:
These handoff practices have been developed primarily for inpatient settings; however, these practices are equally relevant in the outpatient setting, although they require adaptation. For example, the most appropriate strategy will depend on whether the outpatient handoff is temporary or permanent. For temporary transitions (e.g., vacation coverage), verbal sign-out may be limited to "acute" patients while a structured written document (ideally linked to an EMR) provides a snapshot of each patient. Permanent transfer require different approaches. While it is important to prepare all patients for a transfer, when an outpatient transfer involves termination of a longer-standing relationship, both the outgoing and incoming clinician should specifically address the meaning of this "loss" with the patient. In addition, the new outpatient clinician inheriting a large panel of patients, many of whom will not be seen for weeks or even months, might call or send a letter to patients to provide key contact information and begin the process of establishing a therapeutic relationship.
For trainees and, as appropriate, other clinicians, it is important to provide training that focuses on handoff-related competencies. For example, training for incoming (less experienced) residents may cover topics such as how to contextualize clinical information, prioritize tasks in the initial visits, address the loss directly with the patient, and inquire what did and did not work in the past. Outgoing (more experienced) residents may benefit from training on how to communicate effectively with new residents across an experience gradient and how to educate and prepare their patients for the transfer, including addressing the relationship loss and anticipating challenges.