AHRQ Patient Safety Network

The Collection > Structured Hand-offs

PATIENT SAFETY PRIMERS
Handoffs and Signouts

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (6)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (169)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (14)

•Medical Complications (3)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (18)

•Psychological and Social Complications (3)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (10)

Resource Types

•Journal Article (142)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (14)

•Special or Theme Issue (3)

•Tools/Toolkit (5)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (30)

•Latent Errors (21)

•Near Miss (1)

Approach to Improving Safety
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Structured Hand-offs

Clinical Areas

•Medicine (141)

•Nursing (25)

•Pharmacy (2)

Target Audience

•Health Care Providers (136)

•Health Care Executives and Administrators (136)

•Non-Health Care Professionals (41)

•Patients (5)

Setting of Care

•Hospitals (151)

•Residential Facilities (3)

•Ambulatory Care (8)

•Outpatient Surgery (1)

•Patient Transport (9)

1 - 20 of 176

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STUDY

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-162.

STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

Health IT implementation stories: HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study.

AHRQ National Resource Center for Health Information Technology.

STUDY

Nurses discuss bedside handover and using written handover sheets.

Johnson M, Cowin LS. J Nurs Manag. 2013;21:121-129.

STUDY

Towards an understanding of the information dynamics of the handover process in aged care settings—a prerequisite for the safe and effective use of ICT.

Lyhne S, Georgiou A, Marks A, Tariq A, Westbrook JI. Int J Med Inform. 2012;81:452-460.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.'

Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-633.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

REVIEW

Review: bringing patient safety to the forefront through structured computerisation during clinical handover.

Matic J, Davidson PM, Salamonson Y. J Clin Nurs. 2011;20:184-189.

STUDY

Task uncertainty and communication during nursing shift handovers.

Mayor E, Bangerter A, Aribot M. J Adv Nurs. 2012;68:1956-1966.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

REVIEW

Can technology improve intershift report? What the research reveals.

Strople B, Ottani P. J Prof Nurs. 2006;22:197-204.

STUDY

Implementing bedside handover: strategies for change management.

McMurray A, Chaboyer W, Wallis M, Fetherston C. J Clin Nurs. 2010;19:2580-2589.

COMMENTARY

Improving patient safety by implementing a standardized and consistent approach to hand-off communication.

Sandlin D. J Perianesth Nurs. 2007;22:289-292.

STUDY

The content and context of change of shift report on medical and surgical units.

Staggers N, Jennings BM. J Nurs Adm. 2009;39:393-398.

STUDY

Barriers and facilitators to nursing handoffs: recommendations for redesign.

Welsh CA, Flanagan ME, Ebright P. Nurs Outlook. 2010;58:148-154.

ORGANIZATIONAL POLICY/GUIDELINES

Health care worker fatigue and patient safety.

Sentinel Event Alert. December 14, 2011;(48):1-4.

REVIEW

Nursing handoffs: a systematic review of the literature.

Riesenberg LA, Leisch J, Cunningham JM. Am J Nurs. 2010;110:24-34.

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