ED Handoffs: Observed Practices and Communication Errors
Abstract
Objective The study objectives were to identify emergency department (ED) handoff practices and describe handoff communication errors among emergency physicians. Methods Two investigators observed patient handoffs among emergency physicians in a major metropolitan teaching hospital for 8 weeks. A data collection form was designed to assess handoff characteristics including duration, location, interruptions, and topics including examination, laboratory examinations, diagnosis, and disposition. Handoff errors were defined as clinically significant examination or laboratory findings in physician documentation that were reported significantly differently during or omitted from verbal handoff. Multivariate negative binomial regression models assessed variables associated with these errors. The study was approved by the institutional review board. Results One hundred ten handoff sessions encompassing 992 patients were observed. Examination handoff errors and omissions were noted in 130 (13.1%) and 447 (45.1%) handoffs, respectively. More examination errors were associated with longer handoff time per patient, whereas fewer examination omissions were associated with use of written or electronic support materials. Laboratory handoff errors and omissions were noted in 37 (3.7%) and 290 (29.2%) handoffs, respectively. Fewer laboratory errors were associated with use of electronic support tools, whereas more laboratory handoff omissions were associated with longer ED lengths of stay. Co…
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Inconsistencies arise between verbal handoffs and EHRs.
“Moreover, this problem can go beyond personal communication; inconsistencies arise between verbal handoffs and EHRs.”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [271]
Errors and gaps may happen when clinicians verbally report a test result differently from what is recorded in the medical files, as well as when critical information from lab results is left out during handoff discussions.
“Errors and gaps may happen when clinicians verbally report a test result differently from what is recorded in the medical files, as well as when critical information from lab results is left out during handoff discussions [271].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [271]
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- Authors
- Maughan, B. C., Lei, L., & Cydulka, R. K.
- Affiliations
- Brown University (US)
- University of Rochester Medicine (US)
- MetroHealth (US)
- Corresponding author
- Maughan, Brandon C.
- ORCID
- Maughan, Brandon C.
- Venue
- The American Journal of Emergency Medicine
- Publisher
- Elsevier BV
- Published
- 2011-06
- Volume
- 29
- Issue
- 5
- Pages
- 502-511
- ISSN
- 0735-6757 (ISSN-L)
- OpenAlex
- W2167926132
- Cited by
- 95
- References
- 30
- Citations by year
- 2026: 8 · 2025: 6 · 2024: 2 · 2023: 3 · 2022: 7 · 2021: 5 · 2020: 4 · 2019: 8 · 2018: 8 · 2017: 6 · 2016: 6 · 2015: 14 · 2014: 3 · 2013: 9 · 2012: 5
- FWCI
- 4.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Emergency Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- patient handover, emergency physicians, laboratory findings, physician documentation, emergency department length of stay
- MeSH terms
- Communication, Continuity of Patient Care, Emergency Service, Hospital, Humans, Length of Stay, Medical Records, Physical Examination, Prospective Studies, Surveys and Questionnaires, Severity of Illness Index, Medical Errors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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