The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a healthcare setting. You will create a plan to improve the s

Enhancing Patient Safety Through Effective Handoff Communication in a Hospital Setting

Alyssa LaPierre
Capella University
NURS-FPX4035
Dr. Maxine Jeffery
May 2025

Enhancing Patient Safety Through Effective Handoff Communication in a Hospital Setting

One of the most critical and vulnerable moments of healthcare delivery is upon the patient handoffs, being handovers of patient care responsibility between nurses or providers. If done poorly, these can cause communication failures, medical errors and cascading patient negative outcomes. Healthcare systems have shown that roughly 80 percent of serious medical errors take place during hand off shifts and in hospital settings this number hits nearly 80 percent (The Joint Commission, 2022). The key factors responsible for handoff related risks are identified and evidence based solutions for improving communication and the role of nursing in care coordination are discussed; essential stakeholders necessary for implementing safety enhancements are also identified.

Several important factors that predispose handoff communication to patient safety risks are identified. However, there is a lack of standardized protocols, thus information transfer between the nurses are inconsistent. It can be a mixture of what we used to have, labs and symptom reports and things like that, and only narrowing it down by relying on verbal reports alone or incomplete handwritten notes or fragmented electronic health record (EHR) documentation. The variability increases the probability that critical information is left out or is improperly understood. Also, time constraints which are particularly high in emergency departments and intensive care units, pose a major challenge. Incomplete information transfer often comes about from the fact that nurses have heavy workloads and are pressured to rush through handoffs. Furthermore, handoff communications are compromised by frequent interruption from phone calls, alarms and other distractions.

These challenges are increased further due to the growing complexity of patient conditions. High risk for 1 or more systemic adverse events (elderly, multiple chronic conditions, high risk medications, rapidly changing conditions) require very thorough and precisely designed handoffs. If, in these transitions, critical details are missed, treatment can be delayed, medications can be wrong or worsening clinical condition can be overlooked. On the other, the traditional practices in healthcare organizations often result in nurses, physicians and specialists all sharing different versions of the priority, with handoffs across shifts destroying the consensus on the priority of the patient and thereby leading to conflicting treatment plans or duplicate testing.

There are evidence based strategies to address these challenges improving handoff safety. Structured frameworks for more complete and accurate transfer of information such as standardized communication tools such as SBAR (Situation, Background, Assessment, Recommendation) and I-PASS (Illness severity, Patient summary, Action list, Situational awareness, Synthesis by receiver), are being employed. Studies show that the use of these tools can cut medical errors by 30%. Handoffs processes between teams can be improved to capture all key patient data through electronic health record systems by automated checklists and real time updates. We’ve found that creating protected time and quiet zones for handoffs that are free from interruptions can boost information retention by 40%. Also, inter-professional simulation training gives teams the opportunity to practice and hone their handoff communication skills in real situations.

Without nurses, safe and effective handoffs are not possible. Nurses are the most consistently up to date set of healthcare providers across shifts to support patient care and need to lead the push for consistently implementing standardized handoff tools and sufficient time to fully transition patients. They can apply verification techniques for critical information they can use such as "read back" and each actively participates in inter-professional huddles to clarify the care plan. These steps help nurses maintain the standards of care and more than just prevent the expensive results of poor handoffs such as hospital acquired conditions, longer lengths of stay and malpractice claims resulting from communication failures. Yet studies indicate that improvements in handoff communication could save hospitals billions and reduce other adverse outcomes which cost hospitals from $8 billion to $12 billion annually.

For handoff improvements to be successfully implemented, it needs both leadership and frontline staff consistent commitment. While not standard protocols or technology solutions, working fluidly amongst disparate organizations can. This will be when nurses and physicians take ownership in this process and save them hours of corrective care.

To prove return on investment of such changes, quality improvement teams should track metrics such as handoff duration, information completeness and downstream errors. Patients and families should be important stakeholders as well. Participation during bedside handoffs at the appropriate time can be another safety check and also promote transparency. Improving handoffs is also not limited to the direct cost savings of reducing errors, but yielding reputational benefits from improved patient satisfaction scores and improved performance on quality metrics tied to reimbursement. Add in shorter patient stays, greater acuity and the margin of error on care transitions becomes even thinner which bolsters the business case for improving handoffs all the more.

Finally, improving handoff communication is an opportunity to increase patient safety and decrease the burden of healthcare costs. Standardize tools, optimize technology system, protect handoff time from interruption and build collaboration between care providers can immediately decrease communication errors in hospitals. In this improvement effort, nurses are central and coordinate care transitions and advocating for best practices. Handoff communication during patient care throughout a hospital setting requires advances from all parties to achieve sustainable improvements with efforts that are safer and of higher quality.

References

Cohen, M. D., Hilligoss, P. B., & Kajdacsy-Balla Amaral, A. C. (2018). BMJ Quality & Safety, 27(3), 223-231. https://doi.org/10.1136/bmjqs-2017-006696

Riesenberg, L. A., Leitzsch, J., & Cunningham, J. M. (2020). Journal of Nursing Care Quality, 35(1), 1-7. https://doi.org/10.1097/NCQ.0000000000000423

Starmer, A. J., Landrigan, C. P., & I-PASS Study Group (2015). Changes in medical errors with a handoff program. The New England journal of medicine, 372(5), 490–491. https://doi.org/10.1056/NEJMc1414788

The Joint Commission. (2022). Sentinel Event Alert 58: Inadequate handoff communication. https://www.jointcommission.org