1. Danis, Diane MS, RN
  2. Klinkner, Gwen MS, RN, APRN,BC-ADM, CDE
  3. Malec, Ann MS, RN, ACNP
  4. Rees, Susan MS, RN

Article Content


The purpose of this clinical improvement project is 2-fold: (1) to implement a standardized approach to handoff communications about patients as they move throughout the hospital and (2) to improve compliance in using the newly developed handoff communications form.



Given the complexity of healthcare environments today, staff is challenged to communicate effectively about patients in order to ensure safety. One of the JCAHO 2006 National Patient Safety Goals requires a standardized approach to handoff communications, given the number of sentinel events that have been attributed to a lack of communication.



A root-cause analysis was initially completed to look at the management of insulin infusions for patients who move throughout the hospital for tests and procedures. A lack of standardized communication was identified as a root cause of issues surrounding the care and safety of these patients. It was also clear that all patients, not just those with insulin infusions, would benefit from a standardized approach to communication.



A CNS-led team designed a handoff form to standardize communication about any patient traveling off of the inpatient units for tests or procedures. After a 4-month pilot on 3 units, the form was implemented to be used hospital-wide. Forms are collected centrally for compliance data analysis.



Initial findings indicate that staff use the handoff form ona regular basis and have increased their communication about patients.



Staff have become more aware of the gaps in communication and the difficulties of communicating within such a complex environment. Dialogue about information that is not being communicated about patients has increased. The volume of forms used reflects an added workload for staff completing the forms as well as for those responsible for data entry.


Implications for Practice:

One of the 2006 National Patient Safety Goals requires that handoff communications must be communicated in a standardized way. Although a written form imposes more work for those completing it and for those doing data entry, it is more efficient and therefore completed more often than communications given in person or by phone. An electronic version of the form is a future goal.