Although service changes between hospitalists are vulnerable transition points for patients, there are no data about how poor communication leads to patient harm. This qualitative study describes deficiencies in handoff communications with a focus on patient harm.


Fourteen hospitalists on a nonteaching service at 1 academic institution were asked to complete anonymous surveys 48 hours after each service change between May and November 2007. Using the critical incident technique, which solicited comments about the service change, hospitalists were asked to recall deficiencies in the communication, near‐miss events that occurred as a result of poor communication, and how uncertainty about patient management was resolved. Physicians were also asked about strategies to improve communication at service change.


Eight‐nine percent (49 of 55) of surveys were completed. Of these, 31% found missing information that should have been discussed at handoff. Three major categories of omitted information emerged from the qualitative analysis: consultant recommendations, details of care plan (eg, “existing line was to be removed — no explanation of plan for dialysis”), and details of controversial management decisions (eg, “potassium levels not followed in patient admitted with hyperkalemia”). Fourteen percent of physicians reported at least 1 near miss or adverse event that occurred as a result of omitted information. Subthemes of near‐miss or adverse events were: poorly coordinated care (eg, “coagulation issue not addressed prior to scheduled procedure leading to delay”), deviation from the standard of care (eg, “almost did not receive nephroprotective regimen prior to cath with angio”), delay in discharge, and dissatisfaction among patients and consultants. Thirty‐seven percent of physicians reported having additional discussions with the preceding physician after their initial communication. These interactions involved: a review of past management, updates on patient progress, and clarification of missing information such as consultant recommendations, discharge plans, and elements of the original assessment (eg, “patient's baseline mental status”). Hospitalists believed that the service change should be more “detailed,” “precise,” and “systematic.” Relaying consultant recommendations was mentioned as a specific area requiring improvement.


Omission of key information during hospitalist service change is common and may lead to patient harm. This suggests the need to improve hospitalist service change with a focus on detailed, precise, and systematic communication.

Author Disclosure:

K. Hinami, University of Chicago, employee; J. Farnan, University of Chicago, employee; V. Arora, University of Chicago, employee.