Rom opened the #RCEM15 session by describing mission-critical communications as any exchange of information whose disruption results in catastrophic failure of the mission at hand. He described how his experience in fire/rescue services lead to research in military, law enforcement, aviation, and other industries with an eye towards emergency and critical care medicine. Clinicians may not normally consider routine communications as “mission critical”, but that is because when they fail it is not as obvious as it is in other industries. “When mission-critical communications fail for firefighters, it becomes a headline. When mission-critical communications fail for healthcare, it becomes a statistic.”

In the United States, when the Joint Commission was searching for the root cause for hospital related sentinel events they found that 70% involved communications, with 50% occurring during patient care handoff, concluding “patient care handoff communications have been identified as a critical safety and quality problem.” 1 2 Worldwide the problem has not only been cited by every major healthcare organization, but even the Wall Street Journal in 2006 referred to patient handoff as “The Bermuda Triangle of Healthcare”. 3 Further investigation tied such communication failures directly to treatment delays, inappropriate treatment, omissions of care, increased length of stay, avoidable readmissions, increased treatment costs, and other minor and major inefficiencies and patient harm. 2 4 5

Duckworth says that the key is to focus on four aspects of patient information in order for all attending providers on the healthcare team to share a “mental model” or understanding of what’s going on, and what actions are immediately needed. These four components are, in order, the focused priority for the patient (what is the crux of the problem?), the history of prior care (what got us to this point?), the patient’s current state (where are we right now?), and the patient’s immediate needs (what is the very next thing that needs to happen?). 6

While healthcare providers tend to pay more attention to handoff during pre-alerts, poor handoff habits tend to get established during the regular transfer of low acuity patients. Research shows that ED staff members typically remember less than half of the information EMS crews give them, and that, in surveys, ambulance staff feel that physicians do not pay attention when EMS is handing off patients. 4,7

This is not so surprising when one considers that similar dynamics caused issues in mission-critical communications in other industries.8 Luckily, healthcare can just as easily turn to those industries for lessons learned and potential solutions. 9 10 In one example when Great Ormond Street Hospital turned to Ferrari’s Formula One racing pit stop crew to teach them how to better handoff patient care. As a result, technical errors dropped by 42% and information omissions decreased by nearly 50%.

The central idea is to not just avoid errors but rather to provide a hand off that allows receiving clinicians or teams to “pick up the ball” and continue forward progress, rather than having to start their assessment and treatment as if the patient just fell in from the sky. Rom’s own work has produced five general recommendations for clinicians to avoid failure and improve efficiency during handoff whether sending or receiving information. 11

For clinicians sending report the recommendations are:

Eye Contact: For clinicians handing over patient care, responsibility, and information, it is critical to begin by ensuring eye contact with the person to whom the patient is being transferred. Especially during team-to-team transfers and situations where receiving clinicians are multitasking this sends the message that “We are communicating now, you and I.”

Environment: Whenever possible minimize noise and interruptions by simply closing the door, pulling a curtain, or moving to a slightly quieter area to give report.

Ensure ABC’s: If there is a true “Focused Priority”, it should be immediately conveyed and performed by the receiving clinician or team. If at all possible, while another receiving clinician is identified to take the handoff report.

Structured Report: Numerous standardized report formats exist from MIST (and variations) to the most widely used, SBAR, originally developed by the US Navy Submarine service. Dozens of others exist with much evidence showing the use of any is better than the use of none, but little evidence supporting the use of one over another.

Supply Documentation: Separate verbal reports of the Priority, Past Hx, Current State, Immediate Needs with the many patient details that can be transferred on paper or electronic report. This helps clinicians avoid clouding their report with non-critical information.

For clinicians receiving report the recommendations are:

Eye Contact: With the same benefits, this can be initiated by reporter or receiver of patient care.

Environment: In many Emergency Departments in the US during “Alert” level team-to-team hand offs, the receiving clinician initiates a “moment of silence” so that all team members stop what they are doing and focus on the reporting EMS provider.

Ensure Understanding: Always ask questions if there is any possibility of misunderstanding.

Summarize: Not a regurgitation of the report that was just given, but rather a summary of the receiving clinician’s mental model, verbalized so that it can be error-corrected by the clinician giving report as well as anyone else on the receiving team.

Supplementary Documents: Again, this is not only a mention of the importance of the receipt of paper documents, but, where possible, details and patient monitoring located so that the entire receiving team can see the same information, contributing to that shared mental model.

To conclude his presentation Capt. Duckworth said that “handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients” according to the Medical Director of the UK National Patient Safety Agency. 12 However, when done properly patient handoff can also provide the opportunity for clinicians to gain a fresh perspective, foster critical thinking and a more collegial experience, and help improve patient satisfaction.


1.        The Joint Commission. Improving Hand-Off Communication. 1, (The Joint Commission, 2007).

2.        The Joint Commission. Handoff Communications. (Joint Commission Resources, 2008).

3.        Landro, L. Hospitals combat errors at the ‘Hand-Off’. (2006). at

4.        Hilligoss, B. & Cohen, M. D. in Biennial Review of Health Care Management 11, 91–132 (Emerald Group Publishing Limited, 2011).

5.        Dawson, S., King, L. & Grantham, H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australasia 25, 393–405 (2013).

6.        Cheung, D. S. et al. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 55, 171–180 (2010).

7.        Talbot, R. & Bleetman, A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emergency Medicine Journal 24, 539–542 (2007).

8.        Coiera, E. W., Jayasuriya, R. A., Hardy, J., Bannan, A. & Thorpe, M. E. C. Communication loads on clinical staff in the emergency department. Med. J. Aust. 176, 415–418 (2002).

9.        FOJP Service Corporation. Handoff Communications: Heeding the Call to Change. in focus Journal for Health Care Practice and Risk Management 5, (2007).

10.     Weinger, M. B. et al. Improving actual handover behavior with a simulation-based training intervention. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 54, 957–961 (2010).

11.     Duckworth, R. L. Rescue Digest. at

12.     British Medical Association. Safe Handover – Safe Patients. 1, (British Medical Association, 2006).