​Implementation of a resident handoff improvement program reduced the rate of medical errors by 23% overall and significantly reduced the rates of specific types of errors, including diagnostic errors, according to the results of a study published in the November 6, 2014, issue of the New England Journal of Medicine. The study, which evaluated 10,740 patient admissions at nine hospitals from January 2011 through May 2013, measured the rates of medical errors, preventable adverse events, and miscommunications and assessed resident workflow. The intervention consisted of a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Although the rate of nonpreventable adverse events did not change significantly following implementation, the rate of preventable adverse events decreased by 30%. In addition, the researchers observed significant increases from the preintervention period to the postintervention period in the inclusion of specified key elements in written documents and oral communications during handoff, but they did not detect any significant changes in the duration of oral handoffs or in resident workflow, including patient/family contact time and computer time. The study was limited to the hospitals' pediatric residency training programs.

HRC Recommends: The results of the study of this resident handoff program add to the body of literature providing evidence that adverse medical events can be prevented. Various programs and tools that improve communication among caregivers include elements such as briefing and debriefing, checklists, handoffs, huddles, and repeat back and teach back.