Table 6 Reasons that led to an incomplete patient handoff resulting in minor and major harm.

The verbal handoff instructions did not contain the most current information

25(64.1%)

6(100%)

The written/electronic handoff instructions did not contain the most current information

18(46.1%)

4(66.6%)

Interruptions during the handoff process

15(38.4%)

2(33.3%)

Language barriers between the residents

2(5.1%)

1(16.6%)

Knowledge base problems from either of the residents

16(41%)

4(66.6%)

Time constraints affecting the outgoing resident

14(35.9%)

2(33.3%)

Time constraints affecting the incoming resident (you)

7(17.9%)

1 (16.6%)

Interpersonal conflicts between the incoming and outgoing residents

6(15.3%)

0(0%)

Lack of an interactive handoff process (handoff instructions given without the opportunity for questions and answers)

22(56.4%)

1(16.6%)

The handoff was conducted in a distracting environment. (e.g., hospital hallway or emergency department)

11(28.2%)

0(0%)

Reasons why residents did not discuss incomplete handoffs resulting in minor and major harm with their colleagues

  Avoid confrontation with their colleagues

4 (30.7%)

1 (100%)

  Lack of time

3 (23%)

0

  No major harm caused to the patient

2(15.3%)

0

  The residents who gave the handoff instructions were more senior than the residents

2(15.3%)

0

  Forgot about it

1(7.6%)

0

  Overwhelmed with long call hours

1(7.6%)

0