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LOT-986 - Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques - BrainDump Information

Vendor Name : IBM
Exam Code : LOT-986
Exam Name : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques
Questions and Answers : 164 Q & A
Updated On : March 21, 2019
PDF Download Mirror : LOT-986 Braindumps
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LOT-986 exam Dumps Source : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques

Test Code : LOT-986
Test Name : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques
Vendor Name : IBM
Q&A : 164 Real Questions

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IBM Creating IBM Lotus Notes

once king of enterprise utility, Lotus Notes is dragging IBM down | killexams.com Real Questions and Pass4sure dumps

Lotus Notes is coming! Or, perhaps it's declining

When IBM purchased Lotus for $three.5 billion in 1995, it seemed as even though the venerable computing colossal was just about to lock up the application trade and coast to unstoppable gains.

Eighteen years later, Lotus appears extra like a millstone round IBM’s neck than a flywheel giving it added speed.

in accordance with a file within the Wall street Journal, in increase of IBM’s this fall revenue release nowadays, Lotus was the weakest performer in IBM’s software portfolio, shedding 6.four p.c of its sales quantity within the first 9 months of 2012.

It doubtless accounts for about $1 billion in annual profits, in keeping with estimates sourced by the WSJ, or one-sixth to 1-fifth of IBM’s typical software company.

ironically, Lotus as soon as led the style towards today’s most well-liked commercial enterprise applied sciences, the collaborative application that helps groups communicate and work collectively on projects. some of the success reports of that area of interest is Yammer, which Microsoft got final year for $1.2 billion. So, why is IBM sitting at the back of the pack as an alternative of leading from the front?

Lotus, which made the first blockbuster “killer app” within the Nineteen Eighties (Lotus 1-2-three, a phenomenally a hit spreadsheet program), went on to create Lotus Notes, a powerful groupware suite that came out within the early Nineties earlier than any one had any theory what “groupware” turned into.

I used it radically at a number of businesses I worked with. firstly, it became mysterious and robust. Like most conclusion-users of Lotus Notes, I used it basically as an e mail program. It had its quirks, nonetheless it worked. however there became an extra dimension to Notes, a powerful, programmable backend that permit you to create databases and workspaces for collaborative work, contact management, advice sharing, and verbal exchange.

these days, we’d call it a collaboration device or a company social-media tool, and it could be net-based and requisites-compliant, like Yammer, Jive, and Huddle. within the absence of requirements, Notes’ engineers had to invent everything themselves, making it a artful but proprietary solution.

however long earlier than those net-based mostly startups got here along, Notes turned into already dropping its cool. The customer software grew to become massive and bloated. It became expensive to implement and elaborate to personalize.

as the information superhighway won recognition in the late Nineteen Nineties, Lotus added specifications, like POP3 and IMAP email interfaces. They didn’t do so well with the requisites branch, youngsters, using any individual who needed to use an online mail client with a Lotus Notes mail server fully insane.

The upshot is that, simply as the cyber web grew to be commonly used, Lotus Notes grew to be stressful and out of date.

certain, it changed into nevertheless powerful, but unlocking the vigor of Notes regularly required professional expertise, giving upward push to a sector of Notes consultants. No shock that these consultants are having a tough time getting taken critically today. The WSJ rates a Notes consultant who complains about his reception:

“i go to a celebration, and i shortly get insulted,” says Eugen Tarnow, a director of the consultancy Avalon business techniques, which sells the growing older e mail software to organizations. “they are saying, ‘Lotus Notes, that’s nevertheless around?’ It’s no fun.”

lamentably, IBM’s engineers realized the magnitude of requisites compliance too late and didn’t bake interoperability into Lotus Notes smartly sufficient or early satisfactory. So, as powerful as Notes could be, it was and is ill-organized to work in today’s API-rich cloud atmosphere.

IBM has greater up to date social-media utility, too, but best makes about $fifty five million per yr from that segment of its company. So the challenge for IBM is to proceed milking as tons revenue as it can from Lotus, while gradually transferring the branding and the revenue to more moderen, sexier traces of business. One illustration: Renaming its annual Lotus conference, Lotusphere, as “Connect2013.” Yeah, that’ll assist.

We’ll be gazing to look if the income record sheds any longer mild on IBM’s efforts to show Notes around. but as for me, I’m now not holding my breath.

photograph credit: Andrew Mason by way of photopin cc


IBM Modernizes Domino company App Platform | killexams.com Real Questions and Pass4sure dumps

information

IBM Modernizes Domino enterprise App Platform
  • by using David Ramel
  • 10/sixteen/2018
  • IBM has modernized Domino, its company app platform with roots within the Lotus Notes ecosystem that debuted in 1989.

    as soon as essentially conventional because the server-aspect phase of Lotus Notes, Domino is a multi-faceted platform that offers app building -- the usage of the speedy-utility-construction strategy -- and greater.

    In revamping the 29-12 months-old platform, IBM has better cloud assist, cell utility building, analytics and boosted the collaboration capabilities that had been a mainstay of Lotus Notes, which grew to become IBM Notes in a 1995 acquisition.

    Two of the most high-quality modernizations within the new IBM Domino v10 are cell app construction capabilities and the embrace of node.js.

    The stronger cell development performance comes in the new IBM Domino mobile Apps, which is being previewed as a beta for which developers can register. Furthering the IBM/Apple company relationship, the offering lets developers create Apple iPad company apps. "IBM Domino additionally replicates statistics between the server and local version of your functions, so your group will also be productive even without network connectivity," the business said.

    builders can also signal on to try out the new node.js help that comes in the IBM Domino AppDev Pack. "Domino developers can request early access to the realm of JavaScript and Node.js during the IBM Domino AppDev Pack," IBM spoke of. "As an add-on to IBM Domino V10, both JavaScript and Domino builders might be capable of raise, integrate, and easily build new purposes the use of IBM Domino statistics."

    yet another new characteristic is the potential for developers to name any rest APIs from Domino applications, enabling the capability, for examples, so as to add Google Maps performance, pull in Salesforce consumer records or leverage IBM's Watson capabilities.

    the brand new Domino v10 stems from a building settlement IBM entered into with HCL applied sciences a year in the past.

    in regards to the creator

    David Ramel is the editor of visual Studio magazine.


    creating a Todo app with IBM Notes and Node.js | killexams.com Real Questions and Pass4sure dumps

    the way to create an easy Todo app the use of

  • IBM Notes, with IBM ODBC Driver
  • Node js
  • express
  • Angular
  • developing the Todos view and Todo form

    Create an todos.nsf database in Notes with a view with the alias identify todos, and a kind referred to as Todo.The todos view, should still have a column known as unid, todoText and todoComplete. The unid column indicates the files universialID.

    Create a kind with the fields, todoText and todoComplete.

    Then create a new Todo doc with some information.

    Configuring the ODBC driver

    You’ll want the IBM ODBC Driver for Notes/Domino. that you can get it from http://www.ibm.com/developerworks/lotus/toolkits.html

    if you need to use the motive force with the Notes client, you’ll should use the 32bit edition.

    down load and install the driver, then beginning up the windows ODBC manager.

    c:\home windows\SysWOW64\odbcad32.exe

    Add a brand new Lotus Notes SQL Driver (*.nsf) Config the driving force, use native for server, and todos.nsf for database.

    I did add my consumer.identification file and my password to the driver, then I don’t have to put in that assistance when connecting to the database later.

    Go to the Connection Pooling tab(in ODBC supervisor), I delivered 600 sec. for the Lotus Notes SQL Driver.

    installing odbc driver for node

    For connection to the odbc in node I’m the usage of the node-odbc driver. The node-odbc driver requires node-gyp, in case you have trouble installing it, read the deploy instructions over at https://github.com/nodejs/node-gyp

    npm deploy odbc

    look at various the connection

    Create a file known as app.js

    node app.js

    if your connection is adequate, it'll print one row with the doc we created past.

    The Todo Expess app

    First we should load our dependencies, create a connection pool, and also set a static folder to put our entrance-conclusion html/css & javascripts.

    the required dependencies, are:

    Create the endpoints for the leisure API.

    GET submit PUT DELETE

    The comprehensive app.js should look like this

    Now our leisure api is achieved.

    There are a lot of tutorials on the way to create an angular Todo apps. instead of repeating that suggestions right here, that you would be able to download the finished Todo app with with both the express app and the Angular entrance-conclusion from https://github.com/nthjelme/notesnodetodo

    after you have downloaded the code, open a console, cd to the folder you downloaded the code, and sort:

    npm installnpm delivery

    Open http://localhost:3000 to your browser, and also you should be able to see the Todo app running! (in case you created the view,form the odbc connection the equal approach as above.)


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    IBM ditches 'Lotus' brand, preps Notes/Domino 9.0 Social Edition | killexams.com real questions and Pass4sure dumps

    I must admit, it’s been awhile since I covered or thought about IBM or Lotus Notes/Domino, but this announcement struck me as particularly interesting.

    In case you missed it, IBM has completely dropped the Lotus moniker. Its next release is IBM Notes/Domino 9.0 Social Edition; the new name really rolls off the tongue doesn’t it? Well there’s a reason IBM has gone this route.

    The IBM name is more widely recognized and the company was readying the Lotus Notes/Domino 8.5.4 with Social Edition features. Now it has rolled everything up into one completely new client/server release (though the focus is moreso on the client-side).

    Note: A Notes/Domino 8.5.4 update is still planned.

    This led me to touch base with a past contact (who wished to remain anonymous).

    “I think it’s about time they dropped the name,” he said. “Holding onto the Lotus brand was going to have more of a negative impact than a positive one.”

    He suggested that the Lotus name is associated with a legacy platform — whether rightly or wrongly. By tweaking the name, Notes/Domino Social Edition is now a “new” idea.   

    Social Edition allows Notes apps to run in a Web browser. Additionally, there are email and calendar enhancements and Xpages improvements, just to name a few.

    While IBM’ers tout returning customers, it remains to be seen how effective the new naming convention and features will prove.

    The Notes/Domino 9.0 Social Edition beta will be available for download a month from today — December 14 — and the official release is expected Q1 2013. This brings up an interesting point.

    Exchange Server 2013 is also slated to release Q1 2013. Is this a coincidence? Yes, it probably is; IBM has been working on these products for a while and the shift has added a bit more work into the process.

    Any thoughts on the announcement? Feel free to email me.


    Is Everybody Working for the Weekend? | killexams.com real questions and Pass4sure dumps

    This is not a typical DKos post (at least, not for me), but this thread over at Kevin Drum's place got me thinking about a very simple question: Do you like your job?

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    I would really love to hear people's thoughts on this topic - and not just in response to my specific questions. Anything related is cool. So please, take the poll & jump right in.

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    Update [2005-7-8 23:0:56 by DavidNYC]: This has been a truly fascinating thread - I encourage you to read all the way through it. There are comments from an extraordinary array of people: A bodybuilder, a tattoo artist, and a horse breeder to name a few of the more unusual jobs.

    But just as importantly, this thread has reminded me of what I love most about Daily Kos: The diversity of backgrounds combined with a universal desire to learn and listen. I think the site is at its best when these traits are showcased, as they are in this thread tonight.


    Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature | killexams.com real questions and Pass4sure dumps

    Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a single patient1 to broader communication issues between physicians and nurses.2 In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases.3–5 The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009.6 Communication problems have long been noted as a major contributing factor to these sentinel events. Sutcliffe et al7 conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.

    Handoffs, the transfer of patient care from one health care provider to another, are known to be vulnerable to communication failures8 and have been called “remarkably haphazard.”9 As defined by the Joint Commission, handoff communication refers to a standardized process “in which information about patient/client/resident care is communicated in a consistent manner.”10

    Retrospective reviews of malpractice claims in the ambulatory setting11 and emergency department12 showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.13 A review of 146 surgical errors found that 41 (28%) involved handoffs.14 Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the reason for the mistake was a problem with handoffs.15

    Numerous surveys document health care staff concern. In an Agency for Healthcare Research and Quality 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that “important patient care information is often lost during shift changes.”16 When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.17

    Reduced resident duty hours were first introduced in New York State in 1989 and were mandated for all U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many have expressed concern about the resultant need for increased handoffs and reduced continuity of patient care.18 As a result of reduced hours, patients can be seen by three different physicians in the first 24 hours of their care.19 Seventy-six percent of 29 surgical residents in a New York study agreed that continuity of care had been negatively affected as a result of duty hours changes.20

    Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been found to lead to increased in-hospital complications,21 preventable adverse events,22 increased cost due to unnecessary tests being ordered by residents not familiar with the patient,19 and diagnostic test delays.21 In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.22

    Night float systems, often implemented to ensure that residents do not exceed duty hours limits, have been noted to result in inadequate information transfer to the covering residents.23 Nurses have expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a new resident night float system agreed that “residents don’t know the patients as well as in the old system.”24

    Other issues surrounding attending physicians’ and residents’ handoffs have been documented. Gandhi25 notes that inadequate handoffs can lead to diffused responsibility, which can be a major contributor to medical errors. In addition, Coiera26 found that health care communications are prone to interruptions, with a third of communication events (30.6%) interrupted.27 Many of these interruptions result in inefficiencies,28 and interruptions during handoffs are likely to lead to failures of working memory,29 which result in decreased recall accuracy.

    In 2006, the average length of stay for all hospitalized patients was 4.8 days.30 Assuming that patient care transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the average patient will be handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.

    In response to concerns about inadequate health care handoffs, a number of national patient safety organizations have highlighted the importance of communication, including the Institute for Healthcare Communication31 and the National Quality Forum. In 2006, the Joint Commission created a new National Patient Safety Goal on handoffs.32 In 2009, the goal remains virtually unchanged, requiring the organization to implement “a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.”33

    As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of poor communication and inadequate handoffs in health care. The purpose of the current study was to identify all English-language articles on resident and/or attending physicians’ handoffs in the United States, conduct a systematic review of research studies, perform a qualitative review of barriers and strategies mentioned across all articles, and identify features of structured handoffs that have been shown to be effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient Care Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.

    Method National initiative work group

    A work group of the National Initiative developed resources and wrote systematic reviews of the literature in support of the National Initiative's goals. We performed this study as one of a series of literature reviews initiated by that group. The methodology that we employed included regular, substantive discussions about manuscript concept and design, such as key questions, inclusion and exclusion criteria, and search strategies. There were critical interchanges among us about all important aspects of each systematic review written by this group, including those for this report, and we reached consensus on how to treat each systematic review. The specific subject, appropriate technique, and final presentation of this systematic review are the product of a progressive, iterative, and qualitative process of refinement.

    Literature search

    We conducted a thorough and systematic literature search of English-language articles published on handoffs from 1987 to June 4, 2008 using Ovid Medline, Medline In-Process & Other Non-Indexed Citations, CINAHL, HealthSTAR, and Christiana Care Full Text Journals@Ovid, followed by reference section review. The search terms used were hand-off$, handoff$, signout$, sign out$, sign-out$, handover$, hand-over$, signover$, and sign-over$. A total of 2,590 articles were identified. All titles were reviewed for possible inclusion, and 401 articles were obtained for further review (Figure 1). Reference sections of all 401 articles were reviewed for additional articles.

    Inclusion criteria

    Articles meeting the following criteria were eligible for review of barriers and strategies: English language, indexed in PubMed, published between 1987 and June 4, 2008, focused on health care handoffs in the United States, and including information about either resident or attending physicians’ handoffs. Articles included in the systematic review had one of the following study designs: randomized controlled trial; nonrandomized trial, with control or comparison group; single-group pre- and posttest, cohort study; single-group cross-sectional research; single-group posttest only, or qualitative research.

    Trained reviewers (J.L. and L.R.) deemed that 46 articles met inclusion criteria for the initial review of barriers and strategies. Using an iterative process, an abstraction form was developed to confirm eligibility for full review, assess article characteristics, and extract data relevant to the study questions. This iterative process started with an initial form, which was used by two reviewers (J.L. and L.R.) to independently abstract data from four articles. The reviewers then met to discuss the abstraction form for inclusion of all relevant data. A second, more detailed form was then created for abstraction. Reviewers (J.L. and J.M.) independently abstracted all data. Most abstraction disagreements were minor, and all disagreements were quickly resolved during discussion, when a consensus was reached on the abstracted data.

    Quality scoring system

    Downs and Black34 created a valid and reliable checklist designed to assess both experimental and observational studies. Two systematic reviews35,36 of published systems (scales and checklists) designed to assess study quality have ranked the scale developed by Downs and Black as one of the best. Both of these systematic reviews went on to suggest that some modifications might be useful, depending on the specific topic and study designs. Therefore, five of us (L.R., J.L., J.M., J.J., J.S.P.) developed a quality scoring form based on this approach, using four of the original items and eight modified items, which yielded scores ranging from 1 to 16, with 16 being the highest possible score (see Chart 1). This quality scoring form contained two items related to study type and sample size, five items related to reporting, and five items related to internal validity.

    If a study included multiple assessment formats, such as interviews and a questionnaire, that resulted in different sample sizes, the largest sample was used as the sample size in the quality scoring form. There was no way to determine the number of independent study participants for each assessment method. Thus, to avoid counting the same study participant multiple times, we credited the study with the largest reported sample only.

    Quality scores were independently obtained from reviewer pairs (L.R. and J.L. or J.J.) for each study. The interrater reliability was assessed for all identified research studies (n = 18). Overall agreement was 97.7%, and Cohen's kappa for agreement between the two reviewers was r = 0.96, P < .001. All differences were resolved through discussion to yield a final quality score for each study.

    Qualitative analysis of barriers and strategies

    Conventional content analysis is a type of qualitative research used when there is limited or no existing theory on the phenomenon of interest.37 This analysis involves an iterative process that allows themes to arise from data. Researchers immerse themselves in the content and allow categories to emerge.37

    All barriers and strategies mentioned in the reviewed articles were identified and listed in phrase format in two continuous lists, one for strategies and another for barriers. Reviewers (J.L. and L.R.) met to compare lists and, through discussion, agreed on final comprehensive lists. Through an inductive iterative process, category labels were created and all phrases were moved to a category or subcategory. The final lists were reviewed by J.M. for coherence and consistency.

    Results

    Forty-six articles describing resident and/or attending physicians’ handoffs were identified. Thirty-three (71.7%) were published between 2005 and 2008 (Figure 2). Content analysis yielded 91 barriers in eight major categories and 140 strategies in seven major categories (Table 1).

    Figure 2

    Figure 2

    Table 1

    Table 1

    Twenty-two articles presented anecdotal data,38–58 one of which had a physician handoffs case example and nursing handoffs research59; three provided circumscribed reviews,60–62 and three were editorials.63–65 The remaining 18 articles reported research on handoffs and were analyzed in depth (see the Appendix).66–83 Only one80 research study did not involve residents or have a graduate medical education focus. Quality assessment scores for the research studies ranged from 1 to 13 (possible range 1–16). Six studies obtained scores of 8 or less, eight had scores between 8.5 and 11.5, and four achieved quality scores of 12 to 13.

    Only 6 of 18 (33.3%) research studies identified effective handoff features.66,67,69,71,77,78 In studies comparing computerized handoff systems with other methods, such as personal handwritten notes, the computerized or electronic system performed better. Residents were more likely to have all patients on their list,67 to report that they received all important information,78 to have increased satisfaction with the handoff system,67 to spend less time in prerounding and rounding activities,67 and to self-report decreased adverse events related to handoffs.77 Others have noted that resident-maintained lists in a database, such as a Microsoft Word file or Excel database, contain content and medication errors.69,71 However, interns using standardized, self-maintained sign-out cards reported fewer poor sign-outs and were more likely to record code status, patient age, and allergies.66

    Discussion

    As stated earlier, we identified 46 articles describing residents’ and attending physicians’ handoffs in the United States. Eighteen were research studies (39.1%), only two of which were randomized controlled trials. The majority (71.7%) of articles were published in recent years, which is not surprising, given the Joint Commission's National Patient Safety Goal on handoffs issued in 2006. However, as demonstrated by our quality assessment scores (see the Appendix), there is a remarkable lack of high-quality outcomes studies. It is notable that one third of the reviewed research studies obtained quality scores at or below 8 (out of a possible 16), and only one study achieved a score of 13.

    One purpose of the current study was to identify features of physicians’ handoffs that have been shown to be effective. Unfortunately, only 6 of the 18 (33.3%) research studies included measures of effectiveness. Of the three studies using computerized handoff systems, one was a stand-alone system,78 and the other two had some linkage with the hospital computer system.67,77 While these all provided a structured template, they also relied to varying degrees on residents to enter information, which introduces an opportunity for errors to occur.69,71 Most of the studies assessing effectiveness used self-reported data, with a few exceptions. Van Eaton and colleagues67 looked at the number of patients missed on resident rounds and showed a decrease from 5 to 2.5 patients/team/month (P = .0001) when using a computerized handoff system. Two other studies assessed errors on resident-maintained handoff forms when compared with the medical record69,71 (a surrogate for actual medical errors) and, not surprisingly, found errors on the resident lists.

    Of note, two survey studies documented a lack of formal handoffs instruction during residency, with 60% to 74.4% (internal medicine72 and emergency medicine,73 respectively) reporting that they have no lectures or workshops on the topic. Although 72.3% of the 185 emergency medicine residency/fellowship program directors studied agreed that standardized handoffs would reduce medical errors,73 the majority did not have a uniform policy or procedure regarding handoffs. Only one of the studies reviewed here included the development, implementation, and assessment of a formal, structured handoffs curriculum.75 Horwitz and colleagues75 provide a comprehensive curricular template for others to use; however, they relied on postsession evaluations of perceived comfort and importance of handoffs. We commend their plan to conduct observation of handoff skills and look forward to their future publications.

    Almost all of the research articles (17 of 18; 94%) were conducted within a residency program. Graduate medical education has taken the lead in conducting handoffs research, which is one demonstration of the value added to health care by medical education.

    Handoff barriers

    We identified 91 barriers to effective handoffs that could be organized into eight major categories. Of barrier categories, communication issues were reported most frequently (30.8%), with general communication barriers ranging from not listening to inadequate communication. Because effective communication is an essential component of handoffs, this was an expected finding. However, hierarchy and social barriers constituted a less intuitive group. Here, we found things such as relational communication barriers and residents not being likely to hand off work to more senior residents, because of a rigid reliance on hierarchical norms that prohibit such behavior. Thus, adequately addressing handoff issues will require more than protocols, structure, and training. Understanding the complex social structures and hierarchies in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, will be required.

    Handoff strategies

    We identified 140 strategies that could be organized into seven major categories. Strategies for standardization were noted most frequently (44.3%), with technological solutions (16.4%), such as computerized handoff systems, next. Interestingly, whereas communication issues constituted approximately one third of barriers, improving communication skills was noted much less frequently (11.4%) as a strategy. Standardization would address some communication issues, but not all, such as language differences. Providing training or education (10%), evaluating the process (7.1%), and addressing environmental issues (5.7%), such as lighting and limiting interruptions and noise, make intuitive sense. However, a less obvious strategy was insuring the recognition that a transfer of responsibility/accountability (5.0%) had occurred.

    Limitations and strengths

    Handoffs in a variety of environments were studied, which makes it difficult to use our findings to formulate barriers and strategies for use in every handoff situation. For example, some techniques may be better applied to inpatient medicine as opposed to the emergency department. In addition, we abstracted barriers and strategies from all sections of the articles studied, including the introduction. This may have resulted in overemphasis of some barriers or strategies, depending on the author's views and on repetition. However, we only counted the same barrier or strategy multiple times if the wording was significantly different in subsequent use and if the two instances could stand alone as different aspects of the same category.

    Another potential limitation is that the barriers and strategies we identified (Table 1) represent the opinions of the authors of the reviewed studies. Further, we identified the barriers and strategies through a qualitative process. Although they seem intuitively relevant, they were not derived from research studies designed to identify handoff barriers and strategies.

    The current study is limited by the Ovid search strategy used. Specifically, the selected search terms may not have included all relevant terms. We strengthened the possibility of identifying all articles that met inclusion criteria by reviewing the reference sections of all obtained articles. Although this strategy minimizes the risk of missing germane studies, it does not eliminate the possibility.

    Publication bias refers to the possibility that high-quality studies with negative results may not have been published. Others have noted that many quality improvement (QI) projects are not published.84 In addition, it has been our observation that some QI projects are published in newsletters, with the authors never submitting them to peer-reviewed journals. Thus, there may be outcomes studies of handoffs that are not in the peer-reviewed literature. However, the explicit search strategy, clear inclusion criteria, and systematic process used to identify and evaluate articles strengthen the quality of this review.

    Although our quality scoring system was based on a validated methodology developed to assess experimental and observational studies together, our system has not been validated across multiple settings and investigators. The relative weightings may require refinement, and there may prove to be additional relevant categories. The system did have a high internal reliability, and reviewers of various educational backgrounds and experience found it straightforward and easy to use. Further, the quality scoring system provides a reproducible template for the assessment of handoffs articles.

    Recommendations

    Numerous authors have noted the dearth of research focused on handoffs.45,57,70,83,85,86 In addition, there are risks involved in implementing interventions without evidence supporting their effectiveness.87 Winters and colleagues87(p1,647) noted that “[n]ational efforts to improve patient safety should be supported by sufficiently strong evidence to warrant such a commitment of resources.”

    Evidence-based practice is informed by high-quality research. Recent publication guidelines for patient safety and quality initiatives have established a framework for standardized reporting.88,89 We recommend that future handoffs studies use the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines.89 Many of the studies reviewed here would have been improved by doing so.

    Others have noted that it may be unreasonable to expect patient safety and quality studies to follow the design rigors of randomized controlled trials.87 However, the RAND/UCLA Appropriateness Method provides a structured, rigorous method to synthesize data from other clinical study types with expert opinion to provide the best available guidelines.90 Unfortunately, the literature on handoffs identified here is not of sufficient quality and quantity to synthesize into evidence-based recommendations.

    Although the Joint Commission is calling for structured handoffs, we identified very little evidence to support the use of any specific structure, protocol, or method. However, direct observation of handoffs in other settings (i.e., NASA mission control, nuclear power, railroad, and ambulance dispatch) with high consequences for error, yielded 21 common strategies,91 which could offer a starting point in the development of health care handoffs research. Our review of the U.S. physicians’ handoffs literature has led us to develop a list of research questions, organized by the content domains of knowledge, attitudes, skills, process outcomes, and clinical outcomes (see List 1).

    Across the United States, hospitals are implementing structured handoff protocols in an effort to comply with Joint Commission requirements. High-quality outcomes studies that focus on systems factors, human performance, and the effectiveness of protocols and interventions are urgently needed. These studies should address the barriers and strategies identified here. In addition, handoffs in different disciplines are likely to have different requirements and issues. For instance, an emergency department handoff will need to have different content than one for inpatient medicine or pediatrics. Therefore, researchers should conduct discipline-specific handoff studies.

    We call for rigorous outcomes studies designed to (1) assess the effectiveness of handoffs, (2) determine the elements of handoffs that lead to improved patient outcomes, and (3) identify the best implementation strategies. Finally, these studies should be reported using the SQUIRE guidelines. Without these studies, hospitals across the United States are destined to waste time, resources, and effort on flawed handoff practices.

    Acknowledgments

    Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian of the Lewis B. Flinn Medical Library, Christiana Care Health System, for conducting literature searches; Dolores Ann Moran, medical library assistant II, and Janice Evans, medical library assistant II, for their assistance in locating articles; and Donald Riesenberg, MD, for feedback on the manuscript.

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    Academic Medicine84(12):1775-1787, December 2009.

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    FAX: +86 10 68179899
    Others: +301 - 0125 - 01258