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Handoff communication: using failure modes and effects analysis to improve the transition in care process
Michelle Freitag1, V Susan Carroll
1Rush Oak Park Hospital, Oak Park, Illinois 60304, USA. susan.carroll25@gmail.com
Quality Management in Health Care
|April 7, 2011
Summary
Improving patient handoff communication using a standardized tool and caring model reduced errors and enhanced patient safety. This initiative focused on shift-to-shift and inter-unit communication, leading to notable gains in patient satisfaction and outcomes.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety
- Nursing Communication
Background:
- Handoff communication is a critical process prone to errors, impacting care delivery and patient safety.
- Existing communication gaps between shifts and units pose significant risks.
Purpose of the Study:
- To proactively evaluate and improve handoff communication processes.
- To reduce errors and enhance patient safety through a structured improvement plan.
Main Methods:
- Utilized Failure Modes and Effects Analysis (FMEA) for risk assessment.
- Standardized handoff tool using Situation, Background, Assessment, and Recommendation (SBAR) format within the Electronic Medical Record (EMR).
- Integrated Jean Watson's caring model and team huddles to foster patient-centered care and communication.
Main Results:
- Piloted changes on a telemetry unit before broader implementation.
- Collected pre- and post-implementation data on patient satisfaction and nurse-sensitive outcomes.
- Observed notable improvements in targeted patient satisfaction and nurse-sensitive outcomes.
Conclusions:
- Standardizing handoff communication with a structured tool (SBAR) and incorporating caring principles improves patient safety and outcomes.
- Sustaining these changes requires ongoing commitment from leadership and care teams.
- The implemented changes demonstrated positive impacts on patient satisfaction and key nursing outcomes.
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