Academic Psychiatry

, Volume 42, Issue 2, pp 262–264 | Cite as

Training Psychiatry Residents in Patient Handoffs Within the Context of the Clinical Learning Environment Review

  • M. Diane Eckert
  • James Agapoff IV
  • Deborah A. Goebert
  • Earl S. Hishinuma
Feature: Educational Case Report

The death of Libby Zion in a New York emergency room in 1984 brought to light patient safety concerns due to residents working long hours with inadequate supervision [1]. As a result, residency programs implemented changes. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) set duty hour limits [2]. However, an unintended consequence of reduced duty hours was the substantial increase in the number of care handoffs between physicians [3]. Inadequate communication among providers was shown to be a top contributor to the root causes of sentinel events [4]. In 2011, ACGME required that “sponsoring institutions and programs must ensure and monitor effective, structured handoff processes to facilitate both continuity of care and patient safety and must ensure that residents are competent in communicating with team members in the hand-over process” [5]. Additionally, the Clinical Learning Environment Review has six focus areas related to these concerns—patient safety,...



This article was supported by the Department of Psychiatry, University of Hawai’i at Mānoa. The contents of this article are solely the responsibility of the authors. The authors would like to express their appreciation to the residents, faculty, and staff of the Department of Psychiatry.

Compliance with Ethical Standards

This paper describes the process and implementation of handoffs and is not considered research. IRB and consent were not required for this project.


On behalf of all authors, the corresponding author states that there is no conflict of interest.


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Copyright information

© Academic Psychiatry 2017

Authors and Affiliations

  1. 1.University of Hawai’i at MānoaHonoluluUSA

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