Improving

Communication
during Nurse to
Nurse Handoff
Process
Jaimee Carroll, Kourtney Chuman, Stephanie Martinez, & Lily
Wong
Background
● Nurses change shift every 8- 12 hours
● Bedside handoff is a time where accountability and
responsibility is transferred from off going nurse to
new ongoing nurse
● Handoffs occur in and among many clinical areas
and during various tasks
● JACHO has identified that 70% of sentinel events
are contributed to lack of communication with more
than half being from improper nurse to nurse hand
off
● Ineffective nurse handoff has lead to adverse
events and increases patient safety risks

(Malekzadeh, Mazluom, Etezadi, Tasseri, 2013)

 Manpower Methods
Senior nurse was too comfortable Nurse assumed she
and assumed she was familiar with knew the patient.
the patient and the process. Did not report new s/s to
The night shift travel nurse on the next shift: the diminished
unit is not comfortable with the bowel sounds.
unit.
Lack of person-to-person sign
Lack of knowledge of evidence-based out
practice for hand-off reports

Fatigued nurses picking up extra High nurse turnover in the hospital.

shifts for the busy unit.
Sentinel
No nurse to nurse report at
event:
the bed Lack of Hospital wide report Resulting in
report sheets or templates. patient
Equipment issues (Pyxis) on No SBAR was given. death
the unit. Too much time spent
on going to the other side of
the unit to get medications. Lack of standardized
procedures and tools.

Machine Material
s
Root Cause Analysis
● What happened?
◦ In this case study, a senior nurse made the
decision to not receive details during the hand off
report from the travel night shift nurse because
she was familiar with the patient. Ultimately, the
patient aspirated and deteriorated due to a lack of
communication amongst healthcare professionals.
● Why did it happen?
◦ A lack of standardized process or tools used to
transfer patient information led to a patient’s death.
● RCA: A senior nurse made the decision to disregard
a complete handoff report, causing her to overlook
the patient’s acuity status.
 Actions to prevent further
occurrence
Strong ● The hospital can implement standardized and
structured handoff protocols.
◦ Rationale: A standardized handoff tools and
procedure will optimize communication, reduce
missing critical information, and inaccuracy of data
transfer (Goldsmith et al., 2010).

Intermediat ● Hire more nurses to increase staffing on the unit.

◦ Rationale: To decrease caseload per RN and
e increase attentiveness for patient needs (Gephart,
2012).

Weak ● Nurses can incorporate SBAR tool into their

handoff report.
◦ Rationale: An evidenced-based strategy used to
improve the effectiveness of interpersonal
communication (Achrekar et al., 2016).
Outcome Measures
● N= Number of standardized handoffs
used
● D= Total number of handoffs
performed on the nursing unit
● Threshold= 98 percent of nurses will
complete standardized handoffs
● Date= The completion of standardized
handoffs will be monitored for three
months
Outcome Measures Type
Adverse Event Outcome:
Three months following the
completion of standardized handoffs
on the unit, the number of preventable
incidents resulting in patient
complications will be reduced by 90
percent.
Stakeholder Analysis

(Rethmeier, 2009)
Force Field Analysis
Forces FOR Change Forces AGAINST Change
(Driving Forces) (Restraining Forces)

● Patient safety ● Lack of time for nurses

● Less risk of illness during hand-off
complications and ● High turnover of nurses
adverse events ● High caseloads
● Lower hospital costs ● Complex patients
● No team cohesiveness
● High patient-to-nurse ratios

Strategies to mitigate restraining forces: Emphasis on patient safety, team

huddles, standardized protocols or mnemonics to promote hand-off reports,
team mentality for patient care, designated time for shift reports (Gephart,
2012)
 References
Achrekar, M. S., Murthy, V., Kanan, S., Shetty, R., Nair, M., & Khattry, N.
(2016). Introduction of Situation, Background, Assessment,
Recommendation into Nursing Practice: A Prospective Study. Asia-Pacific
Journal of Oncology Nursing, 3(1), 45–50. http://doi.org/10.4103/2347-
5625.178171

Gephart, S. M. (2012). The Art of Effective Handoffs. Advances in

Neonatal Care, 12(1), 37-39. doi:10.1097/anc.0b013e318242df86

Goldsmith, D., Boomhower, M., Lancaster, D. R., Antonelli, M., Kenyon, M.

A. M., Benoit, A., … Dykes, P. C. (2010). Development of a Nursing
Handoff Tool: A Web-Based Application to Enhance Patient Safety. AMIA
Annual Symposium Proceedings, 2010, 256–260.

Malekzadeh, J., Mazluom, S. R., Etezadi, T., & Tasseri, A. (2013). A

Standardized Shift Handover Protocol: Improving Nurses’ Safe
Practice in Intensive Care Units. Journal of Caring Sciences, 2(3),
177–185. http://doi.org/10.5681/jcs.2013.022

Rethmeier, K. A. (2009). An outsider view: the journey of leadership.

The overview. Management in Health, XIII(1), 42-45.
doi:10.5233/mih.2009.0003