A plan that was not said

Review and sources

Not clinically reviewed. No clinician has signed this scenario.

• Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255. doi:10.1136/qshc.2008.028654. Audiotape study of 88 sessions and 503 sign-outs; median 35 seconds per patient; anticipatory guidance 0.42 to 0.56 statements per patient; 298 of 503 sign-outs included no questions from the receiver; and 46 of 211 second sign-outs, 22%, omitted or mischaracterised information from the first, the published example being a plan to call the team on a defined trigger becoming, one handover later, that there is nothing to do tonight.
• Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755-1760. doi:10.1001/archinte.168.16.1755. Same cohort; 24 verified sign-out-related problems, 7.5 per 100 patient-days (95% CI 4.6-10.5); omissions of anticipatory guidance in 9 sign-outs and of a plan of action in 14. The authors report that failure to provide anticipatory guidance for likely overnight events produced some of the most serious problems observed. Categories overlap and counts are of omissions rather than of harms.
• Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556. Prospective pre-post study in nine hospitals, 10,740 admissions; medical errors 24.5 to 18.8 per 100 admissions and preventable adverse events 4.7 to 3.3 (both P<0.001), non-preventable adverse events unchanged (P=0.79), significant reductions at six of nine sites, handoff duration unchanged. No control group.
• Starmer AJ, O’Toole JK, Rosenbluth G, et al. Implementation of the I-PASS handoff program in diverse clinical environments. J Hosp Med. 2023;18(1):5-14. doi:10.1002/jhm.12979. Direct observation across 32 hospitals; verbal contingency plans present in 29% before and 78% after; receiver synthesis 31% to 83%. Adverse-event outcomes are resident-reported in an uncontrolled pre-post design, and several authors disclose equity in a company selling handoff training.
• Huber A, Moyano B, Blondon K. Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic. BMC Med Educ. 2024;24(1):1046. doi:10.1186/s12909-024-05880-7. Simulation with 30 physicians and 177 sign-outs; the situation-awareness element including anticipations was absent from 54% of sign-outs, and one participant of 30 spontaneously rephrased what they received.
• Jorro-Barón F, Suarez-Anzorena I, Burgos-Pratx R, et al. Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial. BMJ Qual Saf. 2021;30(10):782-791. doi:10.1136/bmjqs-2020-012370. Cluster-randomised stepped-wedge trial in six units, 1,465 records; compliance with verbal and written items was significantly higher while preventable adverse events per 1000 days did not change, risk ratio 1.0 (95% CI 0.74-1.34).
• McCarthy S, Motala A, Lawson E, Shekelle PG. Use of structured handoff protocols for within-hospital unit transitions: a systematic review from Making Healthcare Safer IV. BMJ Qual Saf. 2025;34(10):680-690. doi:10.1136/bmjqs-2024-018385. Grades the evidence that I-PASS reduces medical errors and adverse events as moderate certainty across roughly ten implementations, and the evidence for other tools as low certainty or single-setting.
• Allen-Dicker J, Kerwin M, Wallins JS, et al. Physician inpatient handoffs — patient and physician outcomes: a systematic review. J Hosp Med. 2025;20(6):607-622. doi:10.1002/jhm.13583. Forty-two studies, six randomised; adverse events improved in 3 of 16 studies and medical errors in 3 of 7; mortality was examined in four studies and improved in none. Sixty-seven percent of studies were in academic centres and 64% involved residents only.