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

Vendor : 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 : April 19, 2019
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LOT-986 Questions and Answers

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

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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

Lotus OKs a Takeover with the aid of IBM for $three.5 Billion : expertise: The deal, if completed, will create a software enormous. Antitrust clearance with the aid of FTC expected. | killexams.com Real Questions and Pass4sure dumps

The computer software industry's first huge hostile takeover fight ended impulsively Sunday when Lotus building Corp. agreed to be acquired by way of IBM Corp. for $3.5 billion, or $64 per share--a modest premium over the $60 per share that IBM had offered simply six days earlier.

In accepting IBM's sweetened offer, Lotus and its amazing-willed chairman, James P. Manzi, have been bowing to the essential truth that IBM changed into inclined to pay twice what Lotus shares had been trading for on the open market--and no other in a similar fashion free-spending suitor become on the horizon.

The deal, if accomplished, will create a ambitious new competitor within the utility enterprise, marrying IBM's muscle and powerful presence in company computing markets with Lotus' computer utility know-how, most importantly a product known as Notes. The aggregate continues to be area to antitrust clearance via the Federal change commission, but most observers expect the deal to be completed.

"Lotus might be a very important and critical part of IBM and IBM's growth method," IBM chairman Louis V. Gerstner Jr. pointed out Sunday. collectively, industry analysts pointed out, IBM and Lotus should be well-located to battle it out with utility chief Microsoft Corp.

opposite to what those near him had expected, Manzi stated he will dwell on to run Lotus as a free-standing subsidiary of IBM. He stressed out that IBM had agreed to maintain Lotus' liberal personnel guidelines in region and otherwise enable Lotus to run its own exhibit, agreements which he said were vital in persuading him to aid the deal.

"within the manner of these negotiations, we now have looked after the personnel, our shareholders, and very importantly our valued clientele," Manzi pointed out. "Our intention is to circulate promptly to deliver the cost of this mixture to the marketplace."

Manzi will turn into a senior vp of IBM, reporting directly to Gerstner.

however cynics were brief to claim that Manzi will probably live on most effective for a transition duration, gaining the Lotus chief's support--and thereby turning a adversarial takeover right into a pleasant merger--was a crucial achievement for IBM. there's now tons much less risk that key personnel will depart, and there's no hazard of a chronic takeover combat that might disrupt Lotus' operations.

Manzi's brief acceptance of a pleasant deal didn't seem to be doubtless on Monday, when IBM launched its shock $three.3-billion bid. Miffed that he changed into counseled handiest 5 minutes earlier than a public announcement and feeling betrayed with the aid of Gerstner's resolution to proceed towards his desires--Lotus had supported IBM through hard times for both businesses--Manzi appeared like a person ready to fight.

"He changed into just steamed," referred to one source close to Manzi. soon, the Lotus chairman changed into making frantic calls to expertise white knights, including AT&T.; however IBM's present, roughly twice the $32.50 at which Lotus' stock closed per week in the past Friday, turned into considered generous, and no person was inclined to bid towards IBM and its cash reserves of $10.5 billion.

On Tuesday, Manzi referred to as Gerstner, and--after "a brief commute to St. Patrick's Cathedral," as he recounted Sunday--he went to Gerstner's manhattan residence. The conferences endured on Wednesday, and Manzi soon all started seeing the deserves of a mix with IBM. due to the fact that Thursday, representatives for both companies were hunkered down in new york hashing out details of the deal.

"finally, Jim is a pragmatist," spoke of an govt close to Manzi. "once he realized that this turned into the most effective alternative, he was going to barter the most suitable deal for Lotus buyers, employees and himself."

indeed, most analysts say the merger makes loads of sense. the two agencies have had a protracted and shut relationship: the Lotus 1-2-three spreadsheet turned into the primary large hit for the IBM very own laptop, and Lotus has endured to enhance application for IBM's OS/2 operating device even after others deserted it in favor of Microsoft home windows.

And IBM is most likely the optimum business to take advantage of the alternatives presented by means of Lotus Notes, a application program that permits agencies of individuals to share files and in any other case work together electronically. This category of utility, known as groupware, is without doubt one of the few foremost segments of the application business that Microsoft is not placed to dominate.

but making Notes into the groupware normal for tremendous businesses requires two things that IBM has and Lotus lacks: funds, and a earnings drive expert in promoting to the company world. Wounded by its battles with Microsoft, Lotus has discovered itself with dwindling supplies to advertise Notes: It posted a $17.5-million loss last quarter as revenue from Notes did not catch up on unexpectedly declining earnings of 1-2-three.

"This serves up some very large opportunities that we failed to have earlier than," Manzi acknowledged on Sunday.

"it be decent information all of the manner round for every person," agreed bill Milton, a Brown Brothers Harriman analyst. "The difficulty became that Lotus would lose its autonomy and its tradition," Milton noted, including that Manzi's decision to reside and run Lotus became a major tremendous.

Lotus sources pointed out many personnel, concerned by using the enterprise's terrible financial efficiency of late and happy to profit their stock holdings, were delighted by using the possibility of a buyout.

Making the combination work, although, might be no effortless trick. Manzi, who stands to take down nearly $78 million in selling his Lotus shares to IBM, has a decidedly blended list as a supervisor, and it be removed from clear how he and Gerstner and the different members of IBM senior management will mesh.

IBM, for its part, has a bad checklist in managing arms-length relationships with smaller corporations peculiarly application corporations. in the late '80s, IBM fashioned alliances with five computer software companies as a part of its laptop application neighborhood. via 1992, IBM dissolved its partnerships, conceding that the test had failed. The agencies, like Platinum application Corp., complained that working with IBM become smothering.

and large mergers such as this one, certainly within the high-tech sector, are at all times fraught with peril, analysts say. AT&T;'S buyout of the NCR desktop business, as an example, has been a large disappointment.

The success or failure of the merger may depend on the chemistry between Manzi and Gerstner, each former consultants at McKinsey & Co.

Manzi has been firmly in handle of Lotus due to the fact 1986, when company founder Mitch Kapor left. It has been a rocky experience on the administration entrance, with repeated waves of government defections.

"he is not very respectable at constructing groups," noted Frank King, a former Lotus vp who spent 19 years at IBM.

amongst his peers within the software business, Manzi is known as anything of a loner. And his tune checklist as Lotus' chief strategist is additionally blended. It become below Manzi's watch that Lotus lost its area on spreadsheets to Microsoft, generally on account of its cussed refusal to strengthen types for the Microsoft home windows working gadget unless plenty later than most different groups.

however, Manzi had the foresight to invest in Notes when few idea it was a worthwhile product, and he has performed well in securing the loyalty of the critical Notes building team and its chief, Ray Ozzie.

Observers mentioned he might also neatly view the probability to be a huge player inside IBM as an new chance, with some speculating that Manzi could eventually have the opportunity to run all of IBM's own computer corporations. although Gerstner turned into noncommittal about it Sunday, or not it's feasible that some of IBM's other pc utility operations could be transferred to Lotus.

"Manzi became making an attempt to take whatever Mitch Kapor created--the 1-2-three enterprise--and turn it into the Notes company," King spoke of. "The clock ran out. The question nevertheless is: Can Notes become a $1-billion business? possibly IBM can do a far better job at answering that question. It certainly can put much more money behind it than Lotus."

* IBM's utility approach: Lotus deal is step one in challenging Microsoft. D1

(begin textual content OF INFOBOX / INFOGRAPHIC)

Can They Get along?

The success of IBM's $3.5-billion buyout of Lotus development Corp. will rely mostly on the connection between IBM Chairman Louis V. Gerstner and Lotus Chairman James P. Manzi, who has agreed to dwell on after the merger.

LOUIS V. GERSTNER, Chairman and chief government, IBM Corp.

Age: 53

training: MBA, Harvard.

outdated experience: Chairman of RJR Nabisco. President of yankee categorical. advisor for McKinsey & Co.

reputation: considered a powerful economic manager, he receives credit score for reversing IBM's long slide. but many remain cautious of his lack of technical abilities.

****

JAMES P. MANZI, Chairman and chief govt, Lotus construction Corp.

Age: forty three

training: master's in economics, Fletcher school of legislations and Diplomacy.

previous experience: advertising director, Lotus development. advisor for McKinsey & Co. Reporter for Gannett Newspapers.

attractiveness: He had the forsight to put money into Notes software, now Lotus' biggest asset. however he has squandered different alternatives and is regularly criticized for erratic administration.

(begin textual content OF INFOBOX / INFOGRAPHIC)

software offers

The merger of IBM and Lotus building Corp. stands out as the greatest in application business history. a glance on the five largest buyout deals involving software businesses:

1. IBM bids for Lotus building Corp., $3.54 billion, June, 1995

2. desktop friends overseas Inc. seeks to acquire Legent Corp., $2.1 billion, may additionally, 1995

three. Novell Inc. acquires WordPerfect Corp. and a few assets of Borland overseas Inc., $1.four billion, March, 1994

four. Sybase Inc. acquires Powersoft Corp., $940 million, February, 1995

5. Pearson PLC acquires utility Toolworks Inc., $462 million, April, 1994

supply: linked Press


IBM researchers create world's smallest magnet | killexams.com Real Questions and Pass4sure dumps

a world group of researchers working at IBMs' San Jose analysis facility introduced currently that that they had created the area's smallest magnet—it become made from a single atom. in their paper posted in the journal Nature, the crew describes their success because the superior restrict in cutting back the dimension of magnetic storage media the use of the classical method—they document that they were able to use the tiny magnet to save a single bit of information.

Ever considering the fact that difficult drives have been invented, scientists have been challenging at work making an attempt to determine how you can make them smaller whereas at the equal time constructing how you can make them more dense in an effort to dangle extra suggestions. because the team at IBM notes, currently, it takes about a hundred,000 atoms to hold a single bit of assistance. If a technique may well be discovered to commercialize their single-atom strategy, they extra word, it will permit for preserving something as massive as Apple's iTunes library of songs on whatever thing as small as a bank card.

To create their tiny magnet, the team used a scanning tunneling microscope to govern holmium atoms placed on a magnesium oxide plate (to keep the magnetic poles strong). applying an electric existing to the microscope's probe allowed for changing the magnetic orientation of the atom between two states, which, the team notes, may well be used to symbolize on/off states for a single little bit of statistics. To study the state, the team measured the magnetic latest passing in the course of the atom. The team notes also that the state of several atoms may well be read or written when the atoms were as close as a single nanometer aside.

IBM has been investing closely in scanning tunneling microscope research for many years, a expertise they have been credited with inventing (Gerd Binnig and Heinrich Rohrer received the Nobel Prize in physics for this accomplishment returned in 1986). these days, they also announced that that they had developed a brand new method that offered a stronger way to measure the magnetic field of individual atoms and in a a bit of linked building, additionally announced that they'd offer the realm's first business "conventional" quantum-computing provider.

greater counsel: Fabian D. Natterer et al. reading and writing single-atom magnets, Nature (2017). DOI: 10.1038/nature21371

Press free up by using Institute for fundamental Science

© 2017 Phys.org

quotation: IBM researchers create world's smallest magnet (2017, March 9) retrieved 20 April 2019 from https://phys.org/information/2017-03-ibm-world-smallest-magnet.html

This doc is discipline to copyright. aside from any reasonable dealing for the intention of deepest analyze or analysis, no half can be reproduced devoid of the written permission. The content material is supplied for counsel functions best.


IBM Cloud, Watson: suffering from OS/2 Warp Deja Vu? | killexams.com Real Questions and Pass4sure dumps

IBM’s newest quarterly monetary results strengthen a growing challenge: The expertise huge may additionally ultimately turn into an additionally-ran in the cloud computing and synthetic intelligence markets. The existing business scenario is a little similar to IBM within the 1990s — which tried and failed to make OS/2 the favored utility platform for customer-server computing — subsequently dropping out to windows pcs together with windows NT and Linux servers.

IBM CEO Ginni Rometty

a part of IBM’s current issue contains the manner it reviews financial outcomes. by using lumping together cloud and cognitive software income into one line merchandise, the company might also in reality be undermining a comparatively good (though removed from stellar) cloud story.

For its Q1 of fiscal 2019, IBM the previous day said:

  • total salary of $18.182 billion, down from $19.072 billion within the corresponding quarter ultimate year.
  • Cloud and cognitive software profits of $5.037 billion, down from $5.116 billion. (be aware: reading that one line, some media reports erroneously noted cloud revenues had been down. really, the cloud revenues rose — which implies the cognitive piece of the company is a laggard, even complicated IBM says cognitive purposes revenues grew 4 %.)
  • web income of $1.591 billion, down from $1.679 billion.
  • The earnings beat Wall street’s expectations, however revenues had been in need of analyst expectations, SeekingAlpha says.

    IBM increase strikes: mixed results

    IBM CEO Ginni Rometty when you consider that 2012 has been reshaping the company for growth markets similar to cloud services, cognitive computing, cellular, safety and greater. IBM has additionally been promoting off slow-growth or no-boom software groups.

    The enterprise’s current popularity, often talking, hasn’t impressed me. among the reasons:

  • Gartner says the global public cloud market will grow 17.three percent in 2019. but IBM’s annual as-a-carrier run price grew only 10 percent 12 months-over-12 months in Q1 2019. AWS and Azure are bigger and are transforming into way more swiftly.
  • The synthetic intelligence market is expected to exceed $191 billion by 2024, representing a compound annual increase rate of 37 percent from about 2018, in line with this document. And yet it’s protected to assert that IBM’s personal cognitive software revenues had been distinctly flat and maybe even down in some areas.
  • next Up: pink Hat received’t keep IBM

    Amazon net functions and Microsoft Azure are working away with the public cloud market, whereas Google Cloud Platform is at least giving chase with some new and inventive MSP-oriented moves.

    because of this, many ISVs (independent utility providers) and MSPs are embracing multi-cloud management options that lengthen across AWS and Azure — and, increasingly, Google. IBM every now and then pops up in that multi-cloud management conversation — however no longer frequently enough, individually.

    IBM’s answer to the cloud problem contains buying red Hat for hybrid-cloud software. The conception: crimson Hat commercial enterprise Linux (RHEL) is terribly typical inside on-premises records facilities and throughout public clouds. purchasing crimson Hat, therefore, gives IBM immediate credibility as a multi-cloud and hybrid cloud application company.

    That’s true. but there are three issues with the IBM-purple Hat approach:

    Challenges and alternatives

    a few bottom-line realities are rather clear:

    In other words, IBM leaders overlooked essentially the most crucial element of the cloud era — they didn’t make Watson effortless to eat.

    OS/2 Warp Deja Vu?: For me, it’s a case of deja vu. Roughly 25 years in the past, IBM OS/2 might also were the strongest operating equipment available on the market. however the most reliable know-how didn’t win as a result of (A) it was complicated to installation/devour and (B) lacked ISV guide. quick ahead to present day, and equivalent developments are surfacing with IBM Cloud and Watson — exceptionally as ISVs flock to Azure and AWS.

    When OS/2’s confined alternatives grew to become clear, IBM went out and acquired Lotus Notes to flow into the faster-boom groupware collaboration market. It turned into a fine stream for about a decade — except Microsoft trade Server sooner or later overwhelmed IBM in that sector.

    IBM: the place’s the Killer theory?

    fast ahead to present day. IBM has pretty much misplaced the public cloud wars, and should acquire purple Hat to are attempting and win the hybrid cloud wars. Amid all that, IBM’s normal business is maintaining up fairly neatly. standard cloud revenues are turning out to be.

    IBM CFO James Kavanaugh

    decent gains and cash circulation will fund R&D, and there are further opportunities on the horizon. Chief amongst them: Areas like Blockchain and protection.

    In safety, IBM delivered double-digit growth in Q1 2019, and has first rate traction with possibility management application and services choices, together with QRadar and Resilient, CFO Jim Kavanaugh noted right through yesterday’s income name. additionally, IBM’s protection intelligence operations and consulting capabilities, which realize and reply to safety threats for valued clientele, are gaining momentum, he delivered.

    these are promising anecdotes. however average, it’s clear to me that IBM’s so-referred to as strategic imperatives haven’t entirely paid off for the company, its purchasers or its companions.


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    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.

    References 1Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826–833. 2Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Qual Saf Health Care. 2003;12:143–148. 3Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor–patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365–1370. 4White AA, Wright SW, Blanco R, et al. Cause-and-effect analysis of risk management files to assess patient care in the emergency department. Acad Emerg Med. 2004;11:1035–1041. 5White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105:1031–1038. 7Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186–194. 8Keyes C. 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Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2613. 16Agency for Healthcare Quality and Research. Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report. Available at: http://www.ahrq.gov/qual/hospsurvey08. Accessed August 24, 2009. 17Sorokin R, Riggio JM, Hwang C. Attitudes about patient safety: A survey of physicians-in-training. Am J Med Qual. 2005;20:70–77. 18Fletcher KE, Parekh V, Halasyamani L, et al. Work hour rules and contributors to patient care mistakes: A focus group study with internal medicine residents. J Hosp Med. 2008;3:228–237. 19Fins JJ. Professional responsibility: A perspective on the Bell Commission reforms. Bull NY Acad Med. 1991;67:359–364. 20Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531–538. 21Laine C, Goldman L, Soukup JR, Hayes JG. 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