Table 4

Factors, Problems, and Strategies Cited in the Literature

External & internal factors that contribute to errorsProblem/barrier associated with patient safety issuesPractice implications (strategies for reducing errors and improving safety)References
Handoff communicationLanguage problems may contribute to problems during handoffs in several ways. Different dialects, accents, and nuances may be misunderstood or misinterpreted by the nurse receiving report. Abbreviations and acronyms that are unique to certain settings may be confusing to a nurse working in a different setting or specialty. Medications may have similar sounding names, increasing risk for confusion.
  • Face-to-face handoff is preferred31, 35 to allow verbal and nonverbal exchanges and interactive communication and questions.47, 48
  • Standardize forms, checklists, or tools (customized as agreed to by clinicians for specific practice areas) so that all users will understand the information from the same context.34
  • Allow opportunity for questions and clarification during the handoff.2, 34, 47, 48
  • Use a “read back” “repeat back” to decrease communications errors.34, 47, 49
  • Use phonetic and numeric clarifications.136
  • Verify information.47
  • Implement safe practice recommendations for communicating critical test results50
  • Speak in simple, clear, straightforward manner and be specific in description of patient and situation.34
  • Avoid the use of abbreviations and jargon, which may not be understood.34, 151
  • Provide definition of ambiguous terms.
  • Allow receiver of handoff to review relevant summary and data (history, treatments, and services) and current information.48
  • Allow for oncoming and offgoing clinicians to assess situation.35
  • Include anticipated problems or changes in report.31
Arora 200531
Barenfanger 200449
Haig 200645
Hanna 200550
ISMP 2005151
Joint Commission47, 48
Joint Commission International Center for Patient Safety 200534
Simpson 200535
Yates 2005136
DistractionsSituational factors during a handoff can contribute to distractions.
  • Provide handoff in a location/environment that minimizes distractions.157
White 2004157
InterruptionsInterruptions are reported to occur frequently in the health care setting.
  • Limit and discourage interruptions.2, 4, 34, 48, 108 and provide coverage of other duties during handoff to support focused transition
Beach 20064
Currie 2002108
Joint Commission 200848
Joint Commission International Center for Patient Safety34
Patterson 20042
NoiseBackground noises such as pagers, phones, overhead paging, equipment noise, alarms, and talking contribute to increased difficulty in hearing report and can lead to inaccurate interpretation of information.
  • Provide handoff in a location/environment that allows those involved in the handoff to clearly hear the information.3
  • Use a “read back” to decrease communications errors.47, 49
  • Use phonetic and numeric clarifications.136
Barenfanger 200449
Joint Commission47
Solet 20053
Yates 2005136
FatigueIncreased errors are noted in nurses working prolonged shifts.
  • Limit the amount of hours worked to reduce fatigue and errors associated with fatigue.58, 153, 154, 155
Hughes & Rogers 2004153
Institute of Medicine 200458
Rogers 2004154
Scott 2006155
MemoryShort-term memory is limited and lapses may occur when large amounts of information are communicated during a handoff.
  • Design systems to reduce reliance on memory.76, 157
  • Use preprinted patient information forms for accuracy and completeness of information in handoff.55
  • Provide health care providers with access to data to reduce reliance on memory in handoff.55, 157
Gosbee & Gosbee 200576
Parker & Coiera 2000152
Pothier 200555
White 2004157
Knowledge/experiences in handoffsNovice nurses and expert nurses have different needs.158
Novice nurses may encounter issues with handoffs.
Novice nurse may need supplemental information during the handoff.

Staff may not have been educated on strategies for an effective handoff and discharge planning.
  • Support novice nurses with orientation and preceptor programs.
  • Provide continuing education programs on effective handoff strategies.45
  • Provide experienced consultants to less-experienced nurses as they may not have skills in their repertoire for advanced problem-solving.37, 84
  • Provide comprehensive, pertinent information, but avoid overload during handoff.78
Benner 1984158
Ebright 200437
Haig 200645
Kerr 200278
Taylor 200284
Written communicationTrying to interpret illegible notes from another provider may create errors in communication.
  • Use electronic strategies to decrease problems with illegibility.159
  • Use standardized processes (customized to a clinical area, practice setting) to assure critical information is communicated in handoff.34, 35
Joint Commission International Center for Patient Safety 200534
Simpson 200535 Upperman 2005159
Variation in processesThere may be wide variance in the way a handoff is conducted that may lead to omission of critical information and contribute to medical and medication errors.
  • Adopt a standardized, consistent approach to the handoff to decrease errors.33,34
  • Adopt and use behavior-based expectations to reduce risks and promote patient safety. Tools to use during handoffs include the 5 Ps for Patient/Project, Plan, Purpose, Problems, Precautions136 and Situation, Background, Assessment Recommendation (SBAR).34, 44, 45
  • Communicate essential patient care information.34
  • Develop and implement a systematic process for the reconciliation of patient’s medications to decrease risk associated with transfers and transitions to other levels of care.130, 131, 132
Bomba & Prakash 200533
Joint Commission 2006132
Joint Commission International Center for Patient Safety 2005, 200634

Haig 200645
Leonard 200444
Massachusetts Coalition for the Prevention of Medical Errors 2005131
USP 2005130
Yates 2005136

From: Chapter 34, Handoffs: Implications for Nurses

Cover of Patient Safety and Quality
Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
Hughes RG, editor.

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