This blueprint outlines the steps that frontline staff can follow to prevent Handoff Communication Errors:
- Use checklists to minimize the likelihood that key information is not discussed.
- Actively participate in handoffs as both the sender and receiver.
- Leave room for the receiver to repeat back the information from the sender and ask questions.
- Reference a written tool during the handoff whenever possible.
- Organize the information in a logical way.
- Communicate a prioritized list of items needing follow up.
- Include contingency planning statements based on the patient’s condition.
- Ask the sender of information to pause, clarify items, or speak slower if needed.
- Conduct face-to-face handoff communications, when possible.
- Include multidisciplinary team members as appropriate.
- Conduct the handoff communication in a dedicated space with no distractions, when possible.
- Maintain a shared expectation (between sender and receiver) of the process.
- Provide illness severity, with priority given to the sickest patient(s).
- Ensure patient assessment is concise, specific, detailed, and well-organized.
- Use verbal and nonverbal indications to signal understanding.
- Make sure read-back is organized, concise, and accurate.
- Have a clear structure for communication of information.
- Use standardized medical terminologies.
- Avoid using abbreviations in both written and verbal handoff communications.
- Make sure the information you convey is accurate, timely, complete, and respectful.
- Ensure patients and family members understand that they should be included in the handoff, when possible:
- Explain to patients and family members the importance of their involvement in the handoff, the purpose of a handoff, and how they can prepare themselves effectively for the handoff.
- Ensure patients and family members know when the handoff is happening and coordinate telephone involvement if the family members cannot be present physically.
- When the handoff is being conducted, watch the nonverbal expressions from patients and family members and pause to inquire with them further if their expressions do not indicate alignment with the clinical team member giving the handoff.
- If there are language barriers, please reach out to the hospital translators.
- Use standardized communication methods, such as I-PASS and SBAR:
- I-PASS: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver.
- SBAR: Situation, Background, Assessment, Recommendation.
- Use closed-loop communication, a communication model based on verbal feedback, when possible:
- Both sender and receiver are focused on the handoff task.
- The receiver accepts the message with acknowledgment of receipt via verbal confirmation, seeking clarification if required.
- The sender verifies that the message has been received and correctly interpreted, thereby closing the loop.
Illness severity (I)
Clearly identify the patient being handed over as either stable, unstable, or someone to be watched/monitored.
Mr. Smith should be monitored closely for signs of respiratory depression because….
Patient summary (P)
1. A summary statement
2. An identification statement, including weight, allergies, code status
3. A description of events leading to current state
4. The medical/surgical history
5. A summary of key events by body system
6. A summary of patient’s social and cultural background
55-year-old male with tobacco abuse. Hypertension managed with amlodipine now with chest pain, working diagnosis of unstable angina. Presents with 1 week of progressive chest pain on exertion, initially relieved with rest but now with diaphoresis and pallor, no relief with rest. Chest Pain: Initial evaluation in ED P72, BP 162/96. Unremarkable physical exam except mild 3/10 chest pain, improved with nitroglycerin. Cardiac markers, labs, and EKG normal. Started aspirin and metoprolol. Planned admission to medicine. Native language is Spanish but can communicate moderately in English. Mentioned that he struggled to get to his primary care physician because he “had to walk for a while to get to the station.”
Action list (A)
1. Provide key action items that need to be accomplished during the next shift.
2. Specify actions to be completed during the shift which are distinct from the broader hospital plan and contingency plans.
3. Include when they should be completed and describe pending results.
1. Re-evaluate blood pressure after metoprolol dose.
2. Monitor chest pain Q1h.
3. Monitor BP and for headache.
4. Repeat cardiac markers and EKG in 6 hours if still in ED.
5. Investigate socioeconomic barriers.
Situation awareness and contingency planning (S)
1.Provide the receiver with specific instructions for what might go wrong.
2. List interventions that have and have not worked.
3. Ensure accepting team is prepared to anticipate
changes in patient status and respond accordingly. 4. Identify resources and chain of command.
5. For stable patients, indicate “I don’t anticipate that anything will go wrong.”
6. Develop clear contingency plans and structure with “If, then” statements.
7. If caring for a patient who cannot receive visitors, consider including whether the patient’s family needs to be updated, at what interval, and/or based on what criteria.
If chest pain worsens, then send stat markers, EKG, give nitroglycerin 0.4 mg SL, morphine 3 mg IV, and oxygen 2 liters and call cath team.
If stays hypertensive > 140/90 over next 30 minutes, give additional dose of IV metoprolol 5 mg. If investigation into socioeconomic status reveals further barriers to recovery after discharge, provide non-clinical resources as needed and communicate needs to subsequent outpatient providers.
Synthesis by receiver (S)
Receiver: Summarize what was heard, ask questions, restate key action/to-do items. Provide a brief, condensed, and prioritized summary of the most important elements of the handoff.
Sender: Do not interrupt receiver as they are summarizing and encourage questions and discussion after the receiver’s read back.
Synthesis by receiver
Give a concise statement of the problem.
Provide the following information:
1. Recent events and immediate safety risks
3. Pertinent past medical history, past surgical history, home medications
4. History since admission
He/she/they has been admitted to the hospital twice in the last year for
Include the following details:
1. Current problems, root causes, and severity
2. Objective and subjective assessment data
3. Diagnostic results
Current plan of care includes:
<medications>, <procedures>, <therapies>, <treatments>, <fluids>, <diet>, <activity>, <treatments>, <nursing care="">.</nursing></treatments></activity></diet></fluids></treatments></therapies></procedures></medications>
Ensure that there is an opportunity for the receiver to ask questions.
Based on this assessment, I would <recommendations>. What questions do you have for me?
This guide outlines the steps that managers can follow to prevent Handoff Communication Errors:
- Establish a shared expectation for communication across your team.
- Ensure there is a written, readily accessible policy outlining the standardized approach to communicate for every interaction across your unit.
- Provide an optimal setting for adequate handoff (e.g., free from distraction, organizing shift structure to ensure clinicians have overlap, etc.).
- Identify high-risk and high-stress environments and audit those working in those environments for typical gaps they face in handoff communications (e.g., paramedics to emergency departments).
- Consistently reinforce communication method for your frontline team.
- Define essential content for written templates and organize according to organizational method for communication.
- Ensure adequate training and documentation of handoff communication competencies and skills, especially for those new to the organization, are available and easily accessible.
- Consider ongoing observation, simulation, role playing, and scenario review as behavior change methods to detect and mitigate drift.
- Routinely reassess your teams’ handoff communication process to identify gaps.
- Clearly define at what point the handoff (and the transfer of accountability) is completed and ensure clarity of this point for those on the frontline.
- Remain vigilant for those on the frontline who are applying the communication method well and recognize their efforts.
- Set the example of and support others in providing just-in-time education while making everyone involved feel safe and supported.
- Measure meaningfully and debrief regularly to sustain efforts.
- Measure and report handoff communication error rates.
- Note trends in areas with low compliance and high-error rates.
- Routinely reassess outcomes.
- Ensure the integrity of the data collected.
- Debrief with multidisciplinary clinicians from multiple facilities on a regular basis to solicit team feedback about barriers to sustained compliance.
- Adjust your improvement plans quickly and nimbly as needed based on the feedback you receive.
- Eliminate barriers to making rapid changes to documentation templates and order sets.
- Instill a mindset of continuous improvement in every individual across your unit.
Initiate a performance improvement project to address the gaps in handoff communication if you identify opportunities for improvement:
- Gather the right project team. Be sure to involve the right people on the team. You’ll want two teams:
- An oversight team (aka advisory team) that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
- The actual project team that consists of 5–7 representatives who are most impacted by the process.
- Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization.
- Patients and family members should be involved in all improvement projects from the beginning, as there are many ways they can contribute to safer care.
- Understand what is currently happening and why.
- Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data and validating the sources.
- The most important action is to go to the point of care and observe.
- Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience.
- The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
- Create a process map once the workflows are well understood that illustrates each step and the best practice gaps the team has identified.
- Brainstorm with the advisory team to understand why the gaps exist, using whichever root cause analysis tool your organization is accustomed to.
- Review the map with the advisory team and invite the frontline to validate accuracy.
- Prioritize the gaps to be addressed and develop an action plan. The action plan should include the following steps:
- Assess the ability of the culture to change and adopt appropriate
- Revise policies and
- Redesign forms and electronic record
- Clarify patient and family education sources and content.
- Create a plan for changing documentation forms and
- Develop the communication
- Design the education
- Clarify how and when people will be held
- Consider the cost effectiveness, time required, potential outcomes, and realistic possibilities of addressing each gap identified.
- Determine which are a priority for the organization to focus on.
- Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
- Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
- Evaluate outcomes, celebrate wins, and adjust the plan when
- Measure both process and outcome metrics.
- Compare your outcomes against other related metrics your organization is tracking. (Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow )
- Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is
- Identify barriers to completion of action plans and adjust the plan if necessary.
- Once you have the desired outcomes in the trial area, consider spreading to other areas.
- Be nimble and move quickly to keep team momentum going and so that people can see the results of their labor. At the same time, don’t move so quickly that you don’t consider the larger, organizational ramifications of a change in your plan.
- Be sure to have a good understanding of the other, similar improvement projects that are taking place so that your efforts are not duplicated or inefficient.
Recommended handoff communication improvement team members:
- Patients and family members
- Clinical educators
- Respiratory, physical, occupational, and speech therapists
- Radiologists, technologists, laboratory specialists
- Admitting and registration staff
- Quality and safety specialists
- Performance improvement specialists
- Information technologists and data analysts
- Case managers and social workers
- Representatives from facilities across the system
Recommended handoff communication processes to assess:
- Information exchanges across and within departments
- Information exchanges in high stress, distracting environments
- Information display in electronic health records
- Use of read-back in all interactions, with both patients and family members and with clinicians
- Use of abbreviations
- Electronic health records entries for each patient
- Use and style of a “warm” handoff
- Use of closed-loop communication
- Use of templates and material to facilitate communication
- Receiver synthesis
- Communication with patients and family members
- Information exchanges upon admission/transfer/discharge
- Interactions with just-in-time education
Typical gaps identified in handoff communication:
- Expectations for communication are not standardized across the entire organization and system.
- Different abbreviations mean different things by discipline/facility.
- There is no way for the sender to know how the receiver interpreted their communication.
- Documenting information in electronic health records is difficult and time consuming.
- There is no incentive to improve communication.
- There is no template for notes or summary reports.
- Environments are too distracting for effective communication.
- New team members and students do not understand how to communicate in the standardized way.
- Reminders or checklists are perceived as not needed, condescending, and insulting.
- Information shared is not relevant to the receiver or the circumstance.
- Checklists are used as “tick boxes” rather than meaningfully.
- Abbreviations are inappropriately used and/or interpreted.
- Emergent patient’s needs interrupt communication.
- Some team members feel as though they are not heard when they try to communicate.
- Patients are not aware of the information exchanged about them.
- Healthcare workers assume that other healthcare workers are literate in a specialty other than their own just because they are healthcare workers.
- Workers do not feel empowered with just-in-time education strategies when a handoff is suboptimal.
- Workers feel attacked or ashamed when being corrected on a handoff.
- There is a low level of trust and/or psychological safety in the work environment.
This protocol outlines the steps that executives can follow to prevent Handoff Communication Errors:
Communication is the root cause of most patient care errors because hospitals lack a systematic, universal method to accurately transfer important information. Adoption of clear and consistent communication strategies, whether using I-PASS, SBAR, or another method, has been shown to reduce ineffective handoff communications by nearly 60%, reduce readmission rates by almost half, decrease preventable adverse events by 30%, and decrease medical errors by nearly a quarter. According to a global report by the World Health Organization (WHO), nearly twice as many adverse events occur due to breakdowns in handoff communications compared to those linked with inadequate practitioner skills.
Our highly complex environment with many distractions necessitates the use of a standard method of communication to ensure information is not compromised in the high-risk healthcare environment. Inadequate handoffs are often where safety fails first. In a decade-long study, poor handoffs contributed to nearly 80% of adverse events. Nearly 30% of all malpractice claims are due to failures in communication. Over a five-year period, inadequate handoffs have contributed to 1,744 deaths and $1.7 billion in malpractice costs. It is estimated that some teaching hospitals may conduct 4,000+ handoffs in one day. Without a consistent and organized structure guiding the exchange of information, there are more risks for error. The Agency for Healthcare Research and Quality (AHRQ) reports that nearly 50% of hospital staff believe patient information is lost during transfers.
The Joint Commission has made standardization of handoffs a National Patient Safety Goal. The World Health Organization has introduced prevention of handoff errors as one of the top five patient safety solutions. The Society for Hospital Medicine has elevated handoffs as a core competency for practitioners in the hospital.
- Review all errors associated with communication breakdown on a monthly basis.
- Implement and enforce policies, processes, and practices that promote a psychologically safe work environment and a culture of trust.
- Involve representatives from the public and facilities across the healthcare system to optimize care coordination through shared expectation of communication.
- Align all systems, including policies, protocols, electronic health record interfaces, care coordination forms, educational modules, clinical workflows, etc., to ensure a simple and easy to follow method of communication.
- Ensure that leaders have a simple process to oversee handoff communication improvement work while also considering how it aligns with other initiatives across the organization.
- Consider assessing the following to ensure the presence of solid communication processes:
- Information exchanges at the leadership level.
- Information exchanges between differing levels of hierarchy.
- Information exchanges during transitions of care.
- Information accessibility within electronic health records.
- Ease of access to electronic health records for all appropriate personnel prior to transfer and handoff.
- Communication of electronic health record systems between hospitals, community, and ambulatory care services.
This handbook outlines the steps that patients and their families can follow to prevent Handoff Communication Errors.
We recommend patients and their family members take the following steps to prevent misunderstandings and mistakes when receiving handoff communications (follow-up care updates and instructions) from their healthcare providers:
- Involve family members in handoff communications when possible.
- Ask your clinical team to contact hospital translators to overcome any language barriers.
- Limit any interruptions from electronic devices.
- Verify that you have received and understand the information.
- If abbreviations and/or medical terms are used in the communication, ask your healthcare provider to clarify the terms.
- Do not be afraid of asking for further explanation if something is not clear.
- Ask your healthcare team to:
- Explain the purpose of the handoff communication.
- Explain when and where the handoff communication will take place and how you and your family member(s) can prepare for it.
- Conduct a face-to-face handoff communication when possible.
Resources for the reader:
Agency for Healthcare Research and Quality. Checklists. (2019)
Arora V, et al. Patient handoffs. (2019)
IHI. Patient Safety Essentials Toolkit: IHI. (2019)
PSQH. Patient handoffs: The gap where mistakes are made. (2017)
The Joint Commission. Inadequate hand-off communication. (2017)
Müller M, et al. Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. (2018)
PSQH. Patient handoffs: The gap where mistakes are made. (2017)
Shahid S, et al. Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review. (2018)
Lane-Fall M, et al. Patient – and Team-Level Characteristics Associated with Handoff Protocol Fidelity in a Hybrid Implementation Study: Results from a Qualitative Comparative Analysis. (2023)
Lane-Fall M, et al. Developing a Standard Handoff Process for Operating Room–to-ICU Transitions: Multidisciplinary Clinician Perspectives from the Handoffs and Transitions in Critical Care (HATRICC) Study. (2018)
Sparling Jamie L., et al. Handoff Effectiveness Research in periOperative environments (HERO) Design Studio: A Conference Report. (2023)