1. Rossi, Sharon M. RNC, MS

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It's a busy Saturday morning in the ED when suddenly during routine rounds, a nurse discovers a patient in full cardiac arrest. Why didn't the alarms go off? Why did the monitor fail to alert the staff? A root cause analysis revealed that the monitor didn't have the capability to download the newest version of a necessary software update. The clinical engineering department sent an e-mail message to the nurse manager right before she left for vacation about the need to check the monitor to ensure the download was accepted, but the covering manager wasn't aware of this and didn't perform the necessary check. Could this happen at your hospital? If you answered "no," think again.


Communication failure is a leading cause of adverse events in hospitals. In fact, over the past 10 years, communication failures continue to be the number one root cause of all sentinel events reported to the Joint Commission.1 Similarly, a 2007 National Center for Patient Safety executive summary found that as many as 80% of over 8,000 root cause analysis reports to the VA National Center for Patient Safety involved communication failure as at least one of the primary factors contributing to adverse events and close calls.2


Getting to the root of communication failure

The Joint Commission holds hospital leadership accountable for patient safety, so nurse managers should employ some of the same strategies for hand-off communication that are used in the clinical setting. For example, in reviewing the hypothetical monitor case, the fundamental root cause of the patient's death was the failure to hand-off vital information from one leader to another. Had the hospital required that nurse managers adhere to the same requirements of standard hand-off communication that clinicians do, the outcome would have been much different. First, the clinical engineering department would have called the manager directly or, better yet, would have arranged a face-to-face meeting to provide background information, the assessment, and the required action. The second communication issue in the monitor case is the failure of the unit manager to appropriately and systematically hand off the unit to the covering manager before departing for vacation. It's just as important for nurse managers to establish standardized approaches to hand off unit operations as it is for clinicians who transfer their patients from one care provider to another.


Nurse managers are extremely busy, often multitasking while faced with constant distractions and multiple priorities. A standardized process for manager hand-off communication must be an interactive exchange that allows for questioning between the giver and receiver of information. Reliance on e-mail neither provides an optimal opportunity for interaction nor does it always allow for complete assimilation of the intended message. Why? Because most managers send and receive an incredible volume of e-mails every day. Even the best managers may not fully appreciate the content of every message as they quickly send or review e-mails between meetings or before leaving the hospital. With this concept in mind, there are several practical approaches and tools that managers can use to enhance the hand-off processes at their hospitals.


Out of office considerations

Before you leave for a family vacation or conference, there are several things to consider:


[white diamond suit] Who will cover your absence?


[white diamond suit] Who needs to be notified?


[white diamond suit] How will key stakeholders be notified of your absence and coverage plans?


[white diamond suit] How will the covering manager be prepared to oversee both your unit and your committee meetings in your absence?



First, you must choose a covering manager even if you're only planning to be away for a day. Although some issues can be addressed remotely, many issues can't. Clinical staff and other hospital leaders need to know who to contact when an issue arises that may be time sensitive and include patient safety issues. It's a good idea to identify a primary and secondary covering manager who will be used every time you're out of the hospital. This strategy allows the covering manager to become familiar with the staff, patient population, and issues that may need attention in your absence. Choose a manager who can cover you for the entire duration of your absence. When coverage is shared over several days by several managers, continuity suffers, hand off becomes more difficult, and staff members become easily confused as to who's in charge.


Second, who needs to be notified of your absence? Consider not only your supervisor and direct reports, but also peers, physician partners, and key department leaders. Send an away notice via e-mail and post the e-mail at key locations in your unit; for example, the nursing station and charge nurse clipboard. Most e-mail systems have an auto reply message feature so that the sender of any e-mails will be automatically notified that you aren't in the hospital. Both the away notice and the auto reply should include the dates you'll be out of the hospital and the covering manager's contact information. A voice mail message stating your dates out of the hospital and your covering manager's name and phone number is necessary or you can have your phone forwarded to a reliable colleague or assistant covering your office.


Handing off before you leave

Just as a nurse would never leave at the end of the day without giving report to the oncoming shift, a manager should never go on vacation or planned outage from the hospital without giving a full report of her unit to the covering manager. The Joint Commission's National Patient Safety Goal 2E for standardizing hand-off communication should be used as a guide for hand off to a covering manager. (See Table 1.) Completing "to do" lists before vacation departure can be hectic and stressful. Often, nurse managers find themselves spending the first few days of their vacation thinking about what they may have forgotten to address. Scheduling a meeting with the covering manager before your departure allows for organization around your to do list and reflection time related to current and anticipated issues.

Table 1: Nurse manag... - Click to enlarge in new windowTable 1: Nurse manager hand-off principles

The meeting should occur in your office with minimal distractions. Allow ample time for exchange of information and questions. Outline in writing any pertinent information about your unit that the covering manager needs to be aware of and tasks that must be completed or followed up. Use of a standardized approach, such as a modified SBAR (Situation, Background, Assessment, and Recommendation) format, is recommended. (See Table 2.) This tool allows clear and focused communication of outstanding issues that require attention. It can also be used to record meetings that need to be attended, including specific information about any presentation data if applicable. You can use a spreadsheet to construct the tool, which allows for revision based on coverage circumstances. It can be printed and carried by the covering manager so that real-time information can be recorded by hand and eventually entered into the document.

Table 2: Hand-off co... - Click to enlarge in new windowTable 2: Hand-off communication tool for nurse managers

The covering manager needs to collect and organize information in a systematic manner. A three-folder method is a simple, yet effective, strategy for keeping things organized. Each folder is color coded: Red is for critical must-know information, yellow is for reports or data files that need to be reviewed but aren't critical, and green is for items that are general issues. If the covering manager is attending any meetings in your absence, a useful strategy for capturing the information discussed is to use the agenda to record notes about each topic. The covering manager should collect an extra set of handouts for each meeting and when the meeting is completed, copy the agenda sheet and attach it to the handouts. These can be placed in the yellow folder unless immediate follow-up is required that hasn't been addressed in your absence. If this is the case, the meeting notes should be placed in the red folder.


Lastly, before leaving on vacation, schedule a hand-off meeting for the morning of your first day back. Allow for ample time to review what occurred in your absence, as well as the contents of each folder. The hand-off tool and red folder items should be reviewed initially using supporting information in the yellow folder as needed. Take the time to ask questions, clarify actions, and identify any required next steps.


Say goodbye to communication breakdown

In summary, communication failure remains the number one root cause of sentinel events in hospitals. The Joint Commission requires a standardized approach for hand-off communication between caregivers, but nurse managers are also responsible for a multitude of initiatives effecting patient care. Although the Joint Commission doesn't require a standardized approach for hand-off communication at the leadership level, it does hold hospital leadership accountable for patient safety. Nurse managers must be proactive in ensuring that processes are created to allow for accurate information regarding critical patient and operational communications. The use of tools based on the SBAR format, as well as requiring interactive meetings for sharing critical information, can lead to overall operational efficiency and, ultimately, improved patient safety.




1. The Joint Commission. Sentinel events. [Context Link]


2. National Center for Patient Safety. NCPS medical team training program, executive summary, April 2007. [Context Link]