An Overlooked but Dangerous Handoff… of One Million Patients at a Time

By  |  September 28, 2009 | 

A quick heads up on an article written by a very talented UCSF psychiatrist named John Young, which I had the opportunity to co-author. John observed that, despite all the recent literature about handoffs (such as here and here), no one has given much thought to the Mother of all Handoffs: the transition of outpatient panels from graduating residents to brand new interns that happens around July 1st every year.

In the article, in this week’s JAMA, we point out that the “year-end handoff” carries a number of additional risks above and beyond the usual threat of fumbles. For example,

  • Most handoffs involve two providers of comparable knowledge and experience. The year-end handoff involves a handoff from a seasoned expert (the graduating resident) to a novice (the brand new intern, who was a med student a week earlier);
  • The volume is huge: for an individual resident, the handoff may involve as many as 100-200 patients; for a clinic, often 1000-3000 patients; for the nation, about 1 million handoffs every year. It seems like a near-certainty that individuals and systems will be overwhelmed; 
  • Patients may lose trust or suffer other clinical or psychological deteriorations as they experience the loss of their long-time provider.

John and I argue that the year-end handoff requires a new approach, mostly drawn from emerging best practices for other types of handoffs, but with special attention to the unique features of this transition. Handoffs should be systematized, documentation should be standardized, person-to-person transitions (a face-to-face meeting if possible; a phone conference between outgoing and incoming resident if not) should be facilitated, and faculty mentorship should be robust. We also need research to characterize and quantify the hazards and to test new strategies.

Particularly for those of you in the training business, I hope this article helps stimulate your thinking about these handoffs – they are likely quite risky and it is time they received real attention.


  1. menoalittle September 28, 2009 at 3:11 pm - Reply


    Kudos for this report.

    At a time when flawed handoffs are gaining traction with patient safety organizations, continuity of care and cognitive contact with the same patients is being depreciated. There are complex and variable schedules, hospitalist care sans communication with the outside world, mega-multispecialty groups (a different day, a different attending), limited housestaff work hours;

    and last but not least, haphazard electronic storage of data written in legible gibberish that can not be found when it is needed (where’s Waldo?)

    I was told by our presidents and congress people that these problems will be solved with HIT.

    It is admirable that the patient safety mavens desire to fix the unintended consequences of the programs they and their safety predecessors blindly enacted.

    Best regards,


  2. cuizonbernardo March 10, 2010 at 9:56 am - Reply

    I Love this article

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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