Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Diana Clarke; Kim Werestiuk; Andrea Schoffner; Judy Gerard; Katie Swan; Bobbi Jackson; Betty Steeves; Shelley Probizanski

Commentary

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

August 8, 2012

Clarke D, Werestiuk K, Schoffner A, et al. J Nurs Manag. 2012;20(5):592-8.

View more articles from the same authors.

This commentary discusses how one hospital used appreciative inquiry to identify components of handoffs that can help improve unit-to-unit transfers.

PubMed citation

Available at

Related Resources From the Same Author(s)

Incorrect surgical counts: a qualitative analysis.

October 20, 2010

Towards international consensus on patient harm: perspectives on pressure injury policy.

June 8, 2016

Intentional rounding—an integrative literature review.

August 7, 2019

Pharmacist work stress and learning from quality related events.

November 9, 2016

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study.

March 24, 2010

Review of the Australian Incident Monitoring System.

August 17, 2005

The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting.

March 8, 2023

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

PCA safety data review after clinical decision support and smart pump technology implementation.

June 12, 2013

Medication errors in overweight and obese pediatric patients: a systematic review.

February 9, 2022

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.

March 15, 2006

Quality improvement through implementation of discharge order reconciliation.

June 12, 2013

Reducing medication errors by using applied technology.

August 23, 2006

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort.

March 16, 2022

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

"Teach-back" from a patient's perspective.

March 2, 2016

Strategies to reduce errors associated with 2-component vaccines.

December 2, 2020

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Fear of Covid-19 leads other patients to decline critical treatment.

June 3, 2020

Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital?

July 9, 2008

Effects of health information technology on patient outcomes: a systematic review.

November 16, 2016

Influences observed on incidence and reporting of medication errors in anesthesia.

May 9, 2012

Mistreatment in health care among women in Appalachia.

January 24, 2024

'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.

May 13, 2015

Reversing the rise in maternal mortality.

January 16, 2019

Rapid response teams: what's the latest?

March 14, 2018

Nurses' perceptions of how rapid response teams affect the nurse, team, and system.

March 9, 2011

The road to zero preventable birth injuries.

April 9, 2008

Medical audible alarms: a review.

July 31, 2013

The contribution of sociotechnical factors to health information technology–related sentinel events.

January 27, 2016

Medical improv: a novel approach to teaching communication and professionalism skills.

August 3, 2016

Creating a just culture in the perioperative setting.

March 13, 2024

Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?

June 13, 2012

Structural iatrogenesis—a 43-year-old man with "opioid misuse."

March 6, 2019

Using Plan Do Study Act to transform a simulation center.

July 24, 2013

Don't abandon the "second victims" of medical errors.

April 25, 2012

Adverse events after screening and follow-up colonoscopy.

February 15, 2012

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.

March 6, 2005

The impacts of medication shortages on patient outcomes: a scoping review.

June 19, 2019

Safety during night shifts: a cross-sectional survey of junior doctors' preparation and practice.

October 23, 2013

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

July 15, 2009

Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.

May 26, 2010

HomeNet: ensuring patient safety with medical device use in the home.

June 3, 2009

Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.

April 24, 2013

Trends influencing the cost of care and patient safety.

July 26, 2006

Playing it safe: simulated team training in the OR.

April 23, 2008

Team training for safer birth.

January 6, 2016

Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.

June 12, 2013

Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes.

September 20, 2017

Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study.

May 2, 2018

Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review.

May 27, 2020

Empowering informal caregivers with health information: OpenNotes as a safety strategy.

March 14, 2018

Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic.

October 7, 2020

How long does it take to train a surgeon?

November 18, 2009

Hospital safety climate surveys: measurement issues.

October 20, 2010

A concept analysis of undergraduate nursing students speaking up for patient safety in the patient care environment.

August 3, 2016

Adverse event rates as measures of hospital performance.

September 21, 2011

Technical rationality and the decentring of patients and care delivery: a critique of 'unavoidable' in the context of patient harm.

July 25, 2018

Impact of hospital accreditation on quality improvement in healthcare: a systematic review.

January 17, 2024

Hospital computerized provider order entry adoption and quality: an examination of the United States.

January 5, 2011

Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers?

January 30, 2005

Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.

January 20, 2021

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Patient safety measurement tools used in nursing homes: a systematic literature review.

December 7, 2022

Sleep deprivation: implications for obstetric practice in the United States.

August 26, 2009

Strategies for preventing distractions and interruptions in the OR.

June 19, 2013

Supporting nurses in acute and emergency care settings to speak up.

November 8, 2023

Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.

April 21, 2005

The Canadian interprofessional patient safety competencies: their role in health-care professionals' education.

March 7, 2012

Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital nurses.

August 19, 2020

A mixed-methods systematic review of interventions to address incivility in nursing.

July 15, 2020

A nursing home’s 64-day Covid siege: ‘They’re all going to die’.

June 24, 2020

Incidence and method of suicide in hospitals in the United States.

October 31, 2018

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.

February 9, 2011

Approaches to decreasing medication and other care errors in the ICU.

September 25, 2013

Interruptions and medication administration in critical care.

July 29, 2015

Just culture: the foundation of staff safety in the perioperative environment.

May 12, 2021

Prevalence and sources of duplicate information in the electronic medical record.

October 12, 2022

Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study.

March 4, 2020

Hospital at night: an organizational design that provides safer care at night.

August 10, 2016

A demonstration project on the impact of safety culture on infection control practices in hemodialysis

October 9, 2019

Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups.

February 17, 2016

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents.

April 22, 2015

Diagnostic errors that lead to inappropriate antimicrobial use.

June 3, 2015

Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs.

May 29, 2019

ISMP medication error report analysis.

April 21, 2010

ISMP medication error report analysis.

March 10, 2010

ISMP medication error report analysis.

May 12, 2010

The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration.

January 6, 2016

Using HFMEA to assess potential for patient harm from tubing misconnections.

June 28, 2006

Intimidation: practitioners speak up about this unresolved problem.

October 5, 2005

Unlabeled containers lead to patient's death.

July 13, 2005

Disclosing harmful mammography errors to patients.

December 16, 2009

Hospital doctors' workflow interruptions and activities: an observation study.

March 16, 2011

The dangers of ignoring the Beers criteria—the prescribing cascade.

May 22, 2019

Nurses' perception of error reporting and patient safety culture in Korea.

August 8, 2007

What does it take? A case study of radical change toward patient safety.

March 6, 2005

An integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting.

September 12, 2018

The wicked problem of patient misidentification: how could the technological revolution help address patient safety?

May 1, 2019

Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method.

April 12, 2023

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

WebM&M Cases

Check Twice, Transport Once

May 16, 2022

The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication.

May 29, 2019

Improving Weekend Out Of Hours Surgical Handover (WOOSH).

May 25, 2016

Morning handover of on-call issues: opportunities for improvement.

August 6, 2014

Optimizing transitions of care to reduce rehospitalizations.

July 2, 2014

The limits of checklists: handoff and narrative thinking.

June 25, 2014

Interventions employed to improve intrahospital handover: a systematic review.

June 11, 2014

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

April 30, 2014

Shift change handovers and subsequent interruptions: potential impacts on quality of care.

March 12, 2014

Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative.

February 5, 2014

Developing a medical emergency team running sheet to improve clinical handoff and documentation.

December 11, 2013

Effectiveness of written hospitalist sign-outs in answering overnight inquiries.

November 20, 2013

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Rapid response teams: qualitative analysis of their effectiveness.

June 19, 2013

Quality improvement through implementation of discharge order reconciliation.

June 12, 2013

Medication reconciliation meets its MATCH.

May 29, 2013

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

May 15, 2013

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

May 8, 2013

Development of a checklist of safe discharge practices for hospital patients.

April 24, 2013

Re-Engineered Discharge (RED) Toolkit.

March 27, 2013

Mitigating error vulnerability at the transition of care through the use of health IT applications.

February 20, 2013

Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool.

January 30, 2013

Handovers from the OR to the ICU.

January 23, 2013

Handoff Communication Tools.

January 16, 2013

Moving beyond readmission penalties: creating an ideal process to improve transitional care.

January 16, 2013

Review of computerized physician handoff tools for improving the quality of patient care.

December 12, 2012

"It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge from hospital.

November 21, 2012

Implementing AORN recommended practices for transfer of patient care information.

November 14, 2012

The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.

November 7, 2012

See More About The Topic

Hospitals

Health Care Providers

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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