Michael D. Cohen, PhD, is the recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information.

Handoffs are a critical link in maintaining continuity of care during a hospital stay. Whenever there is a shift change, or when a patient moves between departments (such as from an Emergency Room to an inpatient unit), there should be communication between the personnel who have been caring for the patient, and those who are to assume responsibility. These handoffs have to be done effectively. Root cause analyses of sentinel events find communication breakdowns to be major contributing factors nearly two-thirds of the time, and a large fraction of those problems occur during handoffs.

It seems logical that nurses and doctors should receive some training in how to conduct these vital conversations, but in interviews during my research on handoffs, it has been rare to find a practitioner who learned anything in nursing or medical school about how to hand off effectively.