Assessing current handover practices in surgery: A survey of non-consultant hospital doctors in Ireland.

BACKGROUND: Handovers of care are potentially hazardous moments in the patient journey and can lead to harm if conducted poorly. Through a national survey of surgical doctors in Ireland, this paper assesses contemporary surgical handover practices and evaluates barriers and facilitators of effective handover. METHODS: After ethical approval and pre-testing with a representative sample, a cross-sectional, online survey was distributed to non-consultant hospital doctors (NCHDs) working in the Republic of Ireland. A mixed-methods approach was used, combining data using triangulation design. MAIN FINDINGS: A total of 201 responses were received (18.5%). Most participants were senior house officers or senior registrars (49.7% and 37.3%). Most people (85.1%) reported that information received during handover was missing or incorrect at least some of the time. One-third of respondents reported that a near-miss had occurred as a result of handover within the past three months, and handover-related errors resulted in minor (16.9%), moderate (4.9%), or major (1.5%) harm. Only 11.4% had received any formal training. Reported barriers to handover included negative attitudes, a lack of institutional support, and competing clinical activities. Facilitators included process standardisation, improved access to resources, and staff engagement. CONCLUSIONS: Surgical NCHDs working in Irish hospitals reported poor compliance with international best practice for handover and identified potential harms. Process standardisation, appropriate staff training, and the provision of necessary handover-related resources is required at a national level to address this significant patient safety concern.

Banff scoring of kidney allograft biopsies: "Manual" application vs software-assisted sign-out.

OBJECTIVES: Pathologists interpreting kidney allograft biopsies using the Banff system usually start by recording component scores (eg, i, t, cg) using histopathologic criteria committed to memory. Component scores are then melded into diagnoses using the same manual/mental processes. This approach to complex Banff rules during routine sign-out produces a lack of fidelity and needs improvement. METHODS: We constructed a web-based "smart template" (software-assisted sign-out) system that uniquely starts with upstream Banff-defined additional diagnostic parameters (eg, infection) and histopathologic criteria (eg, percent interstitial inflammation) collectively referred to as feeder data that is then translated into component scores and integrated into final diagnoses using software-encoded decision trees. RESULTS: Software-assisted sign-out enables pathologists to (1) accurately and uniformly apply Banff rules, thereby eliminating human inconsistencies (present in 25% of the cohort); (2) document areas of improvement; (3) show improved correlation with function; (4) examine t-Distributed Stochastic Neighbor Embedding clustering for diagnosis stratification; and (5) ready upstream incorporation of artificial intelligence-assisted scoring of biopsies. CONCLUSIONS: Compared with the legacy approach, software-assisted sign-out improves Banff accuracy and fidelity, more closely correlates with kidney function, is practical for routine clinical work and translational research studies, facilitates downstream integration with nonpathology data, and readies biopsy scoring for artificial intelligence algorithms.

A scoping review of clinical handover mnemonic devices.

Since the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System in 1999, clinical handovers (or handoffs) and their relationship with the communication of patient safety have raised concerns from the public, regulatory bodies, and medical practitioners. Protocols, guidelines, forms, and mnemonic devices have been created to ensure safer clinical handovers. An initial literature search did not find a framework to describe the clinical processes and functions of each mnemonic device and its elements. The absence of a systematic framework could hinder the study across and the reusability of the established clinical handover mnemonic devices. This study aims to develop a universal framework to describe the clinical processes and functions essential for patient safety during handover. We queried PubMed.gov and obtained 98 articles related to clinical handovers. We examined the citing sources of the mnemonics mentioned in these articles. A total of 42 handover mnemonics with 238 elements were identified. Our review noted that there was no taxonomy to describe the clinical functions and process associated with the clinical handover mnemonic devices. We used grounded theory to address this gap and built a new taxonomy from the 42 mnemonics. A researcher read all mnemonics, developed a taxonomy for tagging clinical handover mnemonics, and categorized all mnemonic elements into correct processes and functions. After that, the second researcher, a medical practitioner, examined the taxonomy and made suggested corrections for the labelled functions of all mnemonic elements. Both researchers agreed on the taxonomy and the labelled processes and functions of different mnemonic elements. The taxonomy contains three processes and twenty functions in clinical handovers. Clinical processes like 'medical condition', 'medical history', 'medical evaluation', 'care plan', 'outstanding care/tasks/results', and 'patient information', as an administrative process, were widely adopted in clinical handover mnemonics. Moreover, mnemonic elements on communication manner and information validation had been identified in the list of clinical handover mnemonics. Although we recognize challenges because of both the vast number of clinical handover scenarios and the task of placing them under a few predefined groups, our findings suggest that such a taxonomy, as developed for this study, could assist medical practitioners to devise a clinical handover mnemonic to best fit their workplace.

Evaluating the Implementation of a Medical Student's Handoff Curriculum During the Surgery Clerkship.

INTRODUCTION: Early introduction to essential communication skills is important. We sought to determine if a handoff curriculum (HC) would improve confidence, decrease anxiety, and increase participation in clinical handoffs during the surgical clerkship. METHODS: A multi-center prospective cohort study was performed at two medical schools. Training in the intervention group (HC) consisted of a didactic lecture, video review, and practice session. Students completed a pre-clerkship knowledge test and confidence/anxiety/handoff experience questionnaire pre- and post-clerkship. RESULTS: There were no significant differences in pre-clerkship handoff experiences between institutions except having previously witnessed a verbal handoff (School A 96.4% versus School B 76.2%, P = 0.01). While there were no significant differences in post-clerkship confidence or anxiety, HC students were significantly more involved with written sign-outs (52.9% versus 18.2%, P = 0.02) and verbal handoffs (29.4% versus 4.6%, P = 0.03). CONCLUSIONS: Medical students exposed to handoff training shared similar confidence and anxiety scores compared to those that were not, however, they were more involved in handoff experiences during their surgical clerkship. Early introduction to handoff skills may encourage greater participation during subsequent clinical experiences.

Comparison of a formatted versus traditional sign out process for physicians in the emergency department.

INTRODUCTION: Frequent interruptions, critically ill patients, and high patient turnover can make Emergency Department (ED) physician transitions of care (TOCs) challenging. Currently, there is no strict format for TOC in the ED. We structured a formatted ED TOC and evaluated the comparative effects from traditional TOC practice on the perceived quality of sign-out among physicians working in the ED. METHODS: We performed a prospective pre/post-interventional study utilizing convenience sampling in an urban community teaching hospital. The primary outcome was perceived quality of sign-out, as evaluated by the incoming physician one-hour after TOC, using the handoff-Clinical Evaluation Exercise (h-CEX) score with a 9-point scale for each category: Organized/Efficient, Communications Skills, Included Pertinent Information, Clinical Judgment, Patient Focused, Setting, and Overall Sign-Out Quality. Additional evaluation of unexpected tasks and errors from TOC w performed. RESULTS: We included 344 patient TOC observed, of which 147 (43%) were formatted interventions while 197 (57%) were standard TOCs. After analysis in a random effects model, statistically significant improvements among resident physicians were seen for the formatted TOC: patient focused (mean difference 0.40), setting (mean difference 1.05), and overall (mean difference 0.68). The rate of unexpected tasks and errors were higher in the standard TOC, though not statistically significant. CONCLUSION: Resident physicians saw improvement in several h-CEX categories with a formatted TOC. Consistent with prior studies, a formatted TOC for emergency medicine should be strongly considered, especially among learners.

The effect of distraction on the quality of patient handoff: a randomized study.

OBJECTIVE: The number of patient handoffs has increased in recent years. In addition, technology has advanced in the medical field, leading to most providers carrying smartphones at work. Little is known about the effect of mobile devices and quality of patient handoffs. The objective of this study was to determine whether distraction affects the quality of sign-out among obstetrical providers. DESIGN: A randomized, prospective study was conducted. SETTING: Hospital. PARTICIPANTS INTERVENTION: Obstetrical providers listened to a recorded sign-out vignette. Provider groups either were or were not exposed to a distraction while listening to the vignette. All providers had been told that they would be participating in a trial of two methods of sign-out, although in actuality they were all assigned to a single method. In the distraction arm, the participants were exposed to a 'distracting event' (a phone ring, which was answered by the proctor and followed by a brief conversation) that occurred midway through the vignette. MAIN OUTCOME MEASURE: Providers answered a 14-question survey testing recall of facts included in the vignette. The results of each group were analyzed using Fisher's exact test and Student's t-test. RESULTS: Eighty-eight providers were randomized, 44 in the distraction group and 44 in the non-distracted group. The average scores on the survey were similar between groups (11.0 and 10.8, P = 0.57). In addition, the average scores for questions that occurred after the distraction did not differ between the distracted and non-distracted groups (6.4 vs 6.2, P = 0.42). CONCLUSIONS: We observed that a phone ring and brief response did not affect the obstetrical providers' recall of details of a standardized sign-out. More studies are warranted to determine if more frequent or longer distractions would change results.

Improving Efficiency Using Electronic Medical Record Rounding Report & Sign-Out Report.

INTRODUCTION: Standardized rounding and sign-out reports can improve provider efficiency and satisfaction. The purpose of this quality improvement project was to evaluate implementing an electronic medical record-integrated neonatal intensive care unit-specific rounding report and sign-out report on provider efficiency and satisfaction. METHOD: A pre- and post-quality improvement project was implemented to evaluate the effectiveness of standardized electronic rounding and sign-out reports on a 48-bed level-4 neonatal intensive care unit staffed daily by two neonatologists and four advanced practice providers. RESULTS: The electronic rounding and sign-out reports were implemented on 745 patient encounters. The process of using the electronic rounding report was found to be faster than the paper prerounding report. Completing the standardized sign-out report was faster than the previous method used. DISCUSSION: Improving efficiency is essential for optimizing patient care and improving provider satisfaction. Electronic rounding and standardized sign-out reports can improve efficiency and provider satisfaction.

Desirable Features of an Interdisciplinary Handoff.

Failure of communication of critical information during handoffs is one of the leading causes of medical errors, resulting in serious, yet preventable, adverse events in hospitals across the United States. Recent studies have shown that a majority of these errors occur during patient handoffs, with notable communication gaps in interdisciplinary handoffs. We suggest some features that would improve the handoff usability and effectiveness for interdisciplinary medical and nursing teams while potentially improving patient safety.

Systematic Review of Handoff Mnemonics Literature.

A systematic review of published English-language articles on handoffs is conducted (1987 to June 4, 2008). Forty-six articles describing 24 handoff mnemonics are identified by trained reviewers. The majority (82.6%) have been published in the last 3 years (2006-2008), and SBAR (Situation, Background, Assessment, Recommendation) is the most frequently cited mnemonic (69.6%). Of 7 handoff research articles, only 4 study mnemonics. All 4 of these studies have relatively small sample sizes (10-100) and lack validated instruments. Only 1 study has obtained IRB approval. Scientifically rigorous research studies are needed to assess the effectiveness of handoff mnemonics. These should be published in the peer-reviewed literature using the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Incidental splenic findings in pancreatosplenectomy specimens resected for primary pancreatic lesions.

AIMS: Little has been written on the frequency and nature of incidental splenic lesions diagnosed on histopathological examination of pancreatosplenectomy specimens. METHODS AND RESULTS: For 191 such specimens, incidental histological findings after haematopathologist re-review were tabulated. Cases suspicious for lymphoid malignancy underwent molecular analysis for immunoglobulin heavy and kappa light chain rearrangement. Follow-up was obtained on selected cases. In five cases (3%), the spleen was sampled but not mentioned in the original microscopic report; all were normal on re-review. Otherwise, most (171 of 186, 92%) were initially diagnosed as normal, with 160 (94%) remaining so on re-review. Findings on re-review not initially described (n = 11, 6%) included four cases with splenic morphology suspicious for possible leukaemia/lymphoma involvement. Additional findings included abscess formation, foamy macrophages, necrotising granulomas and simple cysts. Fifteen spleens were initially diagnosed as abnormal; the histopathological process was confirmed in all, including non-necrotising granulomas, cysts, Gamna-Gandy bodies, foamy macrophages, involvement by pancreatic neoplasm and involvement by known chronic lymphocytic leukaemia (CLL). Molecular analysis was performed on the five cases of known/suspected lymphoma and two were positive for monoclonal gene rearrangement, including the known CLL and a previously undiagnosed case with similar immunophenotype. CONCLUSIONS: Incidental splenic findings are not uncommon in pancreatosplenectomy specimens. While most are of limited clinical significance, low-grade lymphoproliferative disorders may go undetected if the spleen is overlooked. We recommend careful observation of splenic findings in these specimens, with a low threshold for haematopathological consultation when in doubt.

"PSYCH-PASS": the Development, Adaptation, and Implementation of a Psychiatric Handoff.

OBJECTIVE: The primary purpose of the study was to develop and implement a psychiatry mnemonic PSYCH-PASS for transitions of care in residency training programs. METHODS: The authors examined areas of improvement in the handoff system with residency training administration, service directors, and psychiatry residents to create PSYCH-PASS, a novel mnemonic that could be integrated in the electronic medical record (EMR). The components of PSYCH-PASS are Patient summary, Situational awareness, "whY" is the patient here, Comorbidities, Hemodynamics, Pharmacology/PRNs, Action list, Specifics, and Synthesis. The authors developed a 14 question pre- and post-survey with a 4-point Likert scale measuring five categories. RESULTS: Pre-survey and post-surveys completed by post-graduate year 2 and 3 residents at Montefiore Medical Center (n = 24) noted increased satisfaction, handoff efficiency, handoff efficiency, accessibility, accuracy, communication, awareness, and adherence to PSYCH-PASS, along with a decrease in frequency of errors. CONCLUSIONS: With promising results across a range of metrics indicating resident-reported positive impacts on patient care, further research on the implementation of PSYCH-PASS and its integration into EMR systems is merited. Future directions include gathering objective data from Epic and expansion of the initiative to other psychiatric services and institutions.

Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center.

BACKGROUND: The World Health Organization (WHO) Surgical Safety Checklist is used globally to ensure patient safety during surgery. Two years after its implementation in the University Hospital Basel's operating rooms, adherence to the protocol was evaluated. METHODS: This mixed method observational study took place in the surgical department of the University Hospital of Basel, Switzerland from April to August 2017. Data collection was via individual structured interviews with selected OR team members regarding checklist adherence and on-site non-participant observations of Team Time Out and Team Sign Out sequences in the OR. Data were subjected to thematic analysis and descriptive statistics compiled. RESULTS: Comprehensive local expert interviews indicated that individual, procedural and contextual variables influenced the application of the checklist. Facilitating factors included well-informed specialists who advocated the use of the Checklist, as well as teams focused on the checklist's intended process and on its content. In contrast, factors such as staff insecurity, a generally negative attitude towards the checklist, a lack of teamwork, and hesitance to complete the checklist, hindered its implementation.The checklist's application was evaluated in 104 on-site observations comprising of 72 Team Time Out (TTO) and 32 Team Sign Out (TSO) sections. Adherence to the protocol ranged between 96 and 100% in TTO and 22% in TSO respectively. Lack of implementation of the TSO was mainly due to the absence of one of the key OR team members, who were busy with other tasks or no longer present in the operating room. CONCLUSION: The study illustrates factors, which foster and hinder consistent application of the WHO surgical safety checklist namely individual, procedural and contextual. It also demonstrates that the TTO was consistently and correctly applied, while the unavailability of key OR team members at sign-out time was the most common reason for omission or incomplete use of the TSO.

Cognitive Errors and Risks Associated with Provider Handoffs.

The emergency department is a challenging environment to practice medicine, primarily due to the pace and logistics of practicing emergency medicine. Cognitive errors and provider handoffs can lead to poor patient outcomes. By acknowledging and addressing cognitive errors, including premature closure, anchoring, and diagnosis momentum, we can potentially improve patient care. Additionally, by completing thorough, yet efficient sign-outs, as per The American College of Emergency Physicians' (ACEP) "Safer Sign Out Protocol," the chances of a poor outcome are further reduced. Below, a case of "migraine headache" is presented, highlighting cognitive errors and the risks associated with provider hand-offs in the emergency department.

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department.

OBJECTIVE: Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool. METHODS: Video recordings of resident TOCS were assessed to capture 4 domains: completeness, synopsis, foresight, and professionalism. In phase 1, 56 TOCS were used to modify the tool and improve reliability. In phase 2, 91 TOCS were used to examine validity. Analyses included Cronbach's alpha for internal structure, intraclass correlation and Cohen's kappa for interrater reliability, Pearson's correlation for relationships between variables, and 95% confidence interval of the mean for resident group comparisons. RESULTS: Cronbach's alpha was 0.52 for internal structure of the tool's subjective rating scale. Intraclass correlation for the subjective rating scale items ranged from 0.70 to 0.80. Cohen's kappa for most objective checklist items ranged from 0.43 to 1. Content completeness was significantly correlated with synopsis, foresight, and professionalism (Pearson's r ranged from 0.36 to 0.62, P values were <0.001). House staff senior residents scored higher (on average) than interns and rotating senior residents in synopsis and foresight. Also, house staff interns scored higher (on average) than rotating senior residents in professionalism. House staff senior residents scored higher (on average) than rotating senior residents in content completeness. CONCLUSIONS: We provide validity evidence to support using scores from the TOCS tool to assess higher-level transfer of care comprehension and communication by pediatric emergency department residents and to test interventions to improve TOCS.

Comparative assessment of content overlap between written documentation and verbal communication: an observational study of resident sign-outs.

OBJECTIVE: Effective sign-outs involve verbal communication supported by written or electronic documentation. We investigated the clinical content overlap between sign-out documentation and face-to-face verbal sign-out communication. METHODS: We audio-recorded resident verbal sign-out communication and collected electronically completed ("written") sign-out documentation on 44 sign-outs in a General Medicine service. A content analysis framework with nine sign-out elements was used to qualitatively code both written and verbal sign-out content. A content overlap framework based on the comparative analysis between written and verbal sign-out content characterized how much written content was verbally communicated. Using this framework, we computed the full, partial, and no overlap between written and verbal content. RESULTS: We found high a high degree of full overlap on patient identifying information [name (present in 100% of sign-outs), age (96%), and gender (87%)], past medical history [hematology (100%), renal (100%), cardiology (79%), and GI (67%)], and tasks to-do (97%); lesser degree of overlap for active problems (46%), anticipatory guidance (46%), medications/treatments (15%), pending labs/studies/procedures (7%); and no overlap for code status (<1%), allergies (0%) and medical record number (0%). DISCUSSION AND CONCLUSION: Three core functions of sign-outs are transfer of information, responsibility, and accountability. The overlap-highlighting what written content was communicated-characterizes how these functions manifest during sign-outs. Transfer of information varied with patient identifying information being explicitly communicated and remaining content being inconsistently communicated. Transfer of responsibility was explicit, with all pending and future tasks being communicated. Transfer of accountability was limited, with limited discussion of written contingency plans.

The Effectiveness of Standardized Handoff Tool Interventions During Inter- and Intra-facility Care Transitions on Patient-Related Outcomes: A Systematic Review.

Improving physician handoffs is a patient safety priority. The authors hypothesize that standardized handoff interventions during care transitions improve patient-related outcome measures. PubMed, Cochrane, PsycINFO, CINAHL, Embase, and Web of Science were searched for publications from 2000 to May 2016. Eligible studies compared standardized handoff intervention(s) with no standardized handoff intervention and measured patient-related outcomes. Studies were evaluated independently for eligibility for inclusion by at least 2 authors in a 2-stage process; 14 articles met inclusion criteria. Only 1 study examined inter-facility transfers. Five categories of patient-related outcomes were identified: clinical complications, length of stay, processes of care, adverse events and errors, and family satisfaction. Interventions consistently improved processes of care; interventions consistently did not affect mortality. The other outcomes demonstrated mixed results. Inconsistent results, heterogeneity of the outcome measures, and limited quality studies limit the ability to draw definitive conclusions about best practices for standardized handoffs during care transitions.

A qualitative study of sign-out processes between primary and on-call residents: relationships in information exchange, responsibility and accountability.

OBJECTIVE: To review a quality improvement event on the process of sign-outs between the primary and on-call residents. DESIGN: A retrospective qualitative study using semi-structured interviews. SETTING: A tertiary academic medical center in Singapore with 283 inpatient Medicine beds served by 28 consultants, 29 registrars, 45 residents and 30 interns during the day but 5 residents and 3 interns at night. PARTICIPANTS: Residents, registrars and consultants. INTERVENTION: Quality improvement event on sign-out. MAIN OUTCOME: Effectiveness of sign-out comprises exchange of patient information, professional responsibility and task accountability. RESULTS: The following process of sign-outs was noted. Primary teams were accountable to the on-call resident by selecting at-risk patients and preparing contingency plans for sign-out. Structured information exchanged included patient history, active problems and plans of care. On-call residents took ownership of at-risk patients by actively asking questions during sign-out and reporting back the agreed care plan. On-call residents were accountable to the primary team by reporting back at-risk patients the next day. CONCLUSION: A structured information exchange at sign-out increased the on-call resident's ability to care for at-risk patients when it was supported by two-way transfers of responsibility and accountability.

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week.

BACKGROUND: The 80h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication. MATERIALS AND METHODS: Surgery Residents were assessed on a 1-5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night's trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication. RESULTS: 50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p<0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p<0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P<0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills. CONCLUSIONS: Trauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs.

BACKGROUND: While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern. OBJECTIVES: The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country. DESIGN: Nationwide survey. PARTICIPANTS: All internal medicine program directors registered with APDIM. MAIN MEASURES: Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs. KEY RESULTS: Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff. CONCLUSIONS: Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.