Handoffs are considered a vulnerable point in the clinical workflow. A recent report by The Joint Commission (TJC) found that nearly 80% of communication errors occur during care transitions. While there has been significant research on handoff tools and their use, it can be argued that there is variability among the handoff tools used in current practice. We conducted a multi-year, longitudinal evaluation on the nature of content and structure of handoffs among residents and nurses in a medical intensive care unit (MICU). In this paper, we report on our top-level findings regarding the use of a body-systems based formatted tool that supported standardized, interactive and effective communication for both medical and nursing practice. We discuss the theoretical and practical implications of our results for the design and development of future handoff tools.
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