Download poster

Download Full Text (331 KB)


Handoffs between providers have increased following the implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions. Properly structured and timed handoffs are essential to patient safety.1 Despite this, studies have shown that errors in code status, medication allergies, and important updates to the problem list are common, all of which can lead to adverse outcomes to patients.2

At Thomas Jefferson University Hospital (TJUH) the 2016 Safety Culture Survey revealed that across all specialties, 37% of residents felt that things “fall through the cracks” when transferring patients from one unit to another.

Our interdepartmental Housestaff Quality and Safety Leadership Council (HQSLC) sought to evaluate and modify the TJUH ICU to floor handoff process. Through engaging our diverse membership, we realized that the ICU to floor handoff process at TJUH lacks standardization. The following areas demonstrated a high degree of variation, and were seen as targets for improvement:

● Timing of handoff: Some departments give the handoff at the time of transfer order, and others at bed assignment.

● Incorporation of best practices: Both verbal and written handoffs should be performed with time for follow up questions by the receiving team

● Closed loop communication: Both sending and receiving teams should clearly communicate the plan of care, and the receiving team should clearly indicate when they have taken over primary responsibility.

Poster presented at: House Staff Quality and Safety Leadership Council conference at Thomas Jefferson University.

Publication Date



The Handoff Culture, Can we change how an ICU to floor transfer works, Thomas Jefferson University


Medicine and Health Sciences

The Handoff Culture: Can we change how an ICU to floor transfer works?