Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors

J Perinatol. 2014 Feb;34(2):149-52. doi: 10.1038/jp.2013.146. Epub 2013 Nov 21.


Objective: To define the core data elements of a neonatal intensive care unit (NICU) handoff compare NICU residents' written and verbal handoff data with real-time, auto-populated data and identify the epidemiology of handoff errors.

Study design: We defined nine core data elements for a NICU patient handoff. We then compared residents' written and verbal handoffs against real-time, auto-populated data for each core element.

Result: A total of 101 NICU patient handoffs (31 unique patients) were analyzed. Per patient, residents made more written errors for infants in critical-care beds than for infants in step-down beds (2.33 vs 1.67, P=0.04). Replacing residents' written handoffs with the gold-standard, auto-populated data would have prevented 92% of written errors.

Conclusion: NICU infants are subjected to many handoff errors. Sicker infants are at higher risk for error. Auto-population can reduce written handoff errors and allow residents more time for training and educational opportunities.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Communication
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal / organization & administration*
  • Internship and Residency*
  • Medical Errors / statistics & numerical data*
  • Patient Handoff / organization & administration
  • Patient Handoff / standards*
  • Pilot Projects
  • Risk Factors