New data favors face-to-face hospital shift change handoffs over electronic

August 27, 2015

Ineffective exchange of information at change of shift is one of the most common causes of medical errors at hospitals across the country. These errors have been estimated by the Institute of Medicine to cause as many as 98,000 preventable deaths annually.

Two new studies from the Richard L. Roudebush Veterans Affairs Medical Center and the Regenstrief Institute provide new insights into end-of-shift handoffs. The authors conclude that in spite of a trend toward computerized checklists, face-to-face communication, including the opportunity to spontaneously ask and answer questions, plays an important role in improving the safety of patient handoffs. 

These findings were based on what was seen when reviewing recorded audio and video of actual end-of-shift handoffs. The findings also support the importance of being able to repair errors and ambiguities in conversations “in the moment” during face-to-face interaction.

Richard M. Frankel, Ph.D., Professor of Medicine, Indiana University School of Medicine | Photo By INDIANA UNIVERSITY

"While it’s faster and easier for a physician to complete a computerized checklist at the end of a shift, checklists don’t typically contain much psycho-social information. For example, the patient refuses to walk because it’s painful, or the patient has been asking for a loved one," said Richard M. Frankel, Ph.D., a VA and a Regenstrief Institute investigator and a professor of medicine at IU School of Medicine.

"But this is the type of information the incoming physician needs to know," Dr. Frankel said. "She or he also needs to know which patients are the sickest and what are the likeliest problems the outgoing staffer thinks the incoming colleague will encounter in the next eight to 12 hours. That's easy to talk about but hard to convey via a static shift checklist. And importantly, asking questions clarifies ambiguity and allows for improvisation."

To read the full news release and learn more about the study, visit