Barriers and facilitators to nursing handoffs: recommendations for redesign.

Catherine Amber Welsh; Mindy E. Flanagan; Patricia R. Ebright

Study

Barriers and facilitators to nursing handoffs: recommendations for redesign.

June 9, 2010

Welsh CA, Flanagan ME, Ebright PR. Nurs Outlook. 2010;58(3):148-154.

View more articles from the same authors.

This study used qualitative techniques to identify essential components of safe and effective patient handoffs between nurses.

PubMed citation

Available at

Related Resources From the Same Author(s)

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.

September 23, 2015

"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

September 16, 2015

Evaluation of a physician informatics tool to improve patient handoffs.

July 29, 2009

Understanding situation awareness in nursing work: a hybrid concept analysis.

April 4, 2012

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

April 3, 2013

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

January 3, 2007

The critical incident technique.

March 27, 2005

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

December 6, 2017

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Playing it safe: simulated team training in the OR.

April 23, 2008

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

March 10, 2010

The teaching of a structured tool improves the clarity and content of interprofessional clinical communication.

April 29, 2009

The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.

April 1, 2015

Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

January 31, 2024

Development of the barriers to error disclosure assessment tool.

September 27, 2017

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial.

January 17, 2018

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

August 18, 2021

Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting.

June 25, 2014

A lethal hidden curriculum—death of a medical student from opioid use disorder.

September 4, 2019

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

March 24, 2021

Validity of Agency for Healthcare Research and Quality Patient Safety Indicators at an academic medical center.

August 21, 2013

Medication errors in community pharmacies: the need for commitment, transparency, and research.

February 20, 2019

ACOG SCOPE: Safety Certification in Outpatient Practice Excellence for Women's Health.

September 5, 2012

The effect of multidisciplinary care teams on intensive care unit mortality.

March 3, 2010

Preventable adverse drug events: descriptive epidemiology.

November 13, 2019

Types and patterns of safety concerns in home care: client and family caregiver perspectives.

March 9, 2016

Speaking up and sharing information improves trainee neonatal resuscitations.

December 12, 2012

Implementation of the safety huddle.

February 8, 2017

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Improving communication and teamwork during labor: a feasibility, acceptability, and safety study.

March 16, 2022

Reducing serious safety events and priority hospital-acquired conditions in a pediatric hospital with the implementation of a patient safety program.

June 6, 2018

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.

July 23, 2008

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study.

November 14, 2018

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

May 22, 2013

Year-end resident clinic handoffs: narrative review and recommendations for improvement.

February 15, 2017

Patient safety instruction in US health professions education.

December 21, 2011

Therapeutic errors involving adults in the community setting: nature, causes and outcomes.

September 9, 2009

Use of maternal early warning trigger tool reduces maternal morbidity.

April 6, 2016

Therapeutic errors among children in the community setting: nature, causes and outcomes.

April 22, 2009

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

March 10, 2010

Reflection on adverse event disclosure in the postsurgical hospital context.

May 20, 2015

Exploring the concept of medication discrepancy within the context of patient safety to improve population health.

December 9, 2009

Electronic health records in ambulatory care- a national survey of physicians.

June 25, 2008

Doctors charged with manslaughter in the course of medical practice, 1795-2005: a literature review.

July 19, 2006

A systematic review of clinical outcomes associated with intrahospital transitions

December 4, 2019

No simple fix for fixation errors: cognitive processes and their clinical applications.

January 13, 2010

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

September 29, 2010

Remote patient monitoring improves patient falls and reduces harm.

October 18, 2023

COVID-19 and open notes: a new method to enhance patient safety and trust.

July 7, 2021

The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non–hospital-affiliated outpatient settings: a systematic review.

February 21, 2018

A comparison of error rates between intravenous push methods: a prospective, multisite, observational study.

November 1, 2017

Misdiagnosis of acute myocardial infarction: a systematic review of the literature.

October 6, 2021

Quality initiatives: developing a radiology quality and safety program: a primer.

August 26, 2009

Perspectives on patient and family engagement with reduction in harm: the forgotten voice.

August 15, 2018

Developing an intervention to reduce harm in hospitalized patients: patients and families in research.

December 5, 2018

Empowering patients and reducing inequities: is there potential in sharing clinical notes?

April 15, 2020

A mixed method study of the merits of e-prescribing drug alerts in primary care.

April 30, 2008

Survey shows that at least some physicians are not always open or honest with patients.

February 22, 2012

Diagnostic heuristics in dermatology—part 1 and part 2.

February 6, 2019

Resident supervision and patient safety: do different levels of resident supervision affect the rate of morbidity and mortality cases?

August 26, 2015

Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning.

December 20, 2017

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

May 6, 2015

Voluntary electronic reporting of medical errors and adverse events.

January 18, 2006

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

The emotional fallout from the culture of blame and shame.

October 18, 2017

Resident shift handoff strategies in US internal medicine residency programs.

March 14, 2018

Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation.

September 19, 2018

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

May 4, 2011

Impact of laws aimed at healthcare-associated infection reduction: a qualitative study.

September 30, 2015

Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.

February 4, 2015

Identifying vulnerabilities in communication in the emergency department.

September 9, 2009

Improving communication in the emergency department.

September 9, 2009

Governing the surgical count through communication interactions: implications for patient safety.

November 15, 2006

Duty hours restriction and their effect on resident education and academic departments: the American perspective.

December 5, 2007

Improving the quality of health care: who will lead?

March 6, 2005

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

November 11, 2009

Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.

January 27, 2010

Communication and shared understanding between parents and resident-physicians at night.

July 13, 2016

Building a culture of safety through team training and engagement.

February 6, 2013

The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project.

April 13, 2022

John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards.

March 6, 2005

Filling the gap: simulation-based crisis resource management training for emergency medicine residents.

May 2, 2018

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Classifying and predicting errors of inpatient medication reconciliation.

July 9, 2008

Identification of in-hospital complications from claims data. Is it valid?

March 6, 2005

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

September 8, 2010

Implementing an error disclosure coaching model: a multicenter case study.

February 22, 2017

A road map for advancing the practice of respect in health care: the results of an interdisciplinary modified Delphi consensus study.

August 8, 2018

Patients managing medications and reading their visit notes: a survey of OpenNotes participants.

June 5, 2019

Use of failure mode and effects analysis to improve emergency department handoff processes.

March 23, 2016

Enhanced time out: an improved communication process.

June 21, 2017

Developing a culture of collaboration in the operating room: more than effective communication.

March 4, 2015

Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study.

November 12, 2014

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

"We can't get along without each other": qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety.

May 17, 2017

Implementing standardized operating room briefings and debriefings at a large regional medical center.

August 5, 2009

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

The frequency and nature of prescribing problems by general practitioners in training (REVISiT).

June 15, 2022

Frequency and types of patient-reported errors in electronic health record ambulatory care notes.

July 1, 2020

Related Resources

Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support.

June 21, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review.

June 9, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Lost in translation--silent reporting and electronic patient records in nursing handovers: an ethnographic study.

November 18, 2020

Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.

November 11, 2020

Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers.

July 8, 2020

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

August 21, 2019

Does a unit shift report "blackout" period improve patient safety?

April 10, 2019

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

Implementing bedside handoff in the emergency department: a practice improvement project.

January 23, 2019

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment.

December 5, 2018

Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.

November 28, 2018

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis.

October 24, 2018

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

More than 1 million potential second victims: how many could nursing education prevent?

June 27, 2018

Effects of the I-PASS nursing handoff bundle on communication quality and workflow.

August 9, 2017

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.

June 28, 2017

Implementation of a modified bedside handoff for a postpartum unit.

June 21, 2017

Factors influencing patient safety during postoperative handover.

December 14, 2016

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

September 21, 2016

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

September 7, 2016

Using Kotter's change model for implementing bedside handoff: a quality improvement project.

August 24, 2016

Promoting patient safety with perioperative hand-off communication.

August 10, 2016

Transformational leadership in nursing and medication safety education: a discussion paper.

June 1, 2016

Standardized handoff report form in clinical nursing education: an educational tool for patient safety and quality of care.

December 9, 2015

Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010–2013).

June 17, 2015

See More About The Topic

Hospitals

Nurses

Nurse Managers

Quality and Safety Professionals

Nurse Care

Barriers and facilitators to nursing handoffs: recommendations for redesign.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Barriers and facilitators to nursing handoffs: recommendations for redesign.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site