During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.

Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.

Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.

Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.

Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.

Handovers between providers occur regularly during hospital stays. This review synthesizes the benefits of, and barriers to, successful handovers. Benefits include humanization of the patient and improved patient safety; barriers include provider stress and feelings of inadequacy. Recognition of these factors can improve successful implementation of handover procedures in hospitals.

The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.

Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.

This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include  improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.

Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.

While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 

This international qualitative study explored strategies employed by nurse managers and directors to prevent missed nursing care. Most strategies, including staffing ratios, communication, and empowering nurse leaders, required complex interventions at the system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and hospital level.

The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.