Developing an error taxonomy system for patient handoff events

This paper develops an error taxonomy system for a framework of analyzing patient handoff events. The taxonomy was composed of four sections: event outline, outcome severity, background factors and prevention mechanisms. Each section included one or more dimensions, each of which had multiple categories. Applying the taxonomy to patient handoff incidents collected from five general hospitals in Japan, we identified several important characteristics of handoff failures. Two handoff types that most frequently failed were inter-department handoffs and nurse-to-nurse shift handoffs in the wards. And the failures were mainly due to insufficient or inaccurate information transfer about medication and patient conditions other than vital signs. Regarding inter-department handoffs, transfer failure of patients, medicines, materials and equipment was also frequently occurred. Staff human factors, organizational factors and busy work situations were three major contributing factors behind patient handoff incidents. Reliability of the taxonomy system was confirmed by interrater reliability.