Courtney Shrader, MLS(ASCP)CM

From 1995-2004 the Joint Commission estimated about 65 percent of 2,966 adverse events were due to communication issues. In 2005, that percentage grew to 70, and half of the events occurred during patient handoffs.2

Due to these startling statistics, in 2006 the Joint Commission created a national patient safety goal to standardize hand-off communication.2 To this day, the Joint Commission still has a national patient safety goal of improving communication due to a 2012 statistic: “80 percent of errors in healthcare can be credited to miscommunication occurring during the transfer of care.”

A hand-off is defined as “transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person or professional group, on a temporary or permanent basis.” Poor communication during hand-offs can lead to a breach in patient safety.1,2 Patient safety is compromised due to incomplete, inaccurate, or omitted data during the hand-off exchange.2,4

“80 percent of errors in healthcare can be credited to miscommunication occurring during the transfer of care.”

Standardized Hand-off Tools
The Joint Commission calls upon hospitals to implement standardized hand-off protocols but does not provide any specific standardized approach.1 There are multiple standardized hand-off tools available, including:

  • SBAR (Situation, Background, Assessment, and Recommendation)
  • I-PASS (Illness severity, Patient summary, Action list, Situation awareness, and contingency planning Synthesis by receiver)
  • ISBAR (Introduction, Situation, Background, Assessment, and Recommendation)
  • NUTS (Name, Unexpected outcomes, Tubes, Safety scan)
  • REED (Record, Evidence, Enquire, and Discuss)
  • Organizational-created checklists3,5,6,7

No matter which type of standardized tool is used, handoff communication is enhanced with a standardized tool by decreasing information overload, increasing the quality of information communicated, decreasing patient safety risks, and improving patient outcomes.3,6 Generally a standardized handoff tool should identify: “the specific hand-off situations to which it applies, who should be involved in the communication, and what information should be communicated.”1 Formal training on how to utilize the standardized hand-off process is key to ensure proper usage.

Hand-offs should be performed in an environment without distractions and interruptions to ensure all information is properly communicated and received, and allow for the opportunity to ask questions.1,2,6,9 Hand-offs are most effective when face-to-face and paired with written documentation of the hand-off.1,2,5,6,9

Gaps in Communication
The perception of the quality of the hand-off varies between the sender and receiver. One study showed that 60 percent of the time the sender perceived they addressed all the pertinent information, but the receiver did not perceive they were given all the pertinent information. The effectiveness of the hand-off by the sender was overestimated.10

One of the biggest gaps in communication starts with the sender not connecting with the receiver.6 The lack of connection stems from the human factor of egocentric thought processes and overestimating the receiver’s understanding.6,10 Utilizing a structured hand-off process that provides a framework of what should be included in a hand-off helps bridge this gap.6 Utilizing the communication skill of feedback loop or reading back the information and having an open dialogue that allows questions to occur ensures that the receiver understands the sender’s message.1,2 A culture of safety must be in place where individuals feel comfortable to ask questions and speak up to ensure information is fully understood.11

A standardized hand-off tool is effective in improving communication during hand-offs, but a single tool is not “one size fits all.” This allows specific departments to create a tool that works for them and include the information they deem important to hand-off to the next shift. It is important to address differences in perception of the effectiveness of the hand-off by providing structure in the hand-off process. Effective hand-offs improve patient safety and create a teamfriendly and patient-centered work environment.


  1. Garrett, M. (2010). Patient Hand-Offs: What’s the Big Deal? Delaware Medical Journal, 141-142.
  2. Groah, L. (2006). Hand Offs-A Link to Improving Patient Safety. AORN Journal, 227-230.
  3. Galatzan, B., & Carrington, J. (2018). Exploring the State of the Science of the Nursing Hand-off Communication. CIN: Computers, Informatics, Nursing, 484-493.
  4. Lee, S.-H., Phan, P. H., Dorman, T., Weaver, S. J., & Pronovost, P. J. (2016). Handoffs, Safety Culture, and Practices: Evidence from the Hospital Survey on Patient Safety Culture. BMC Health Services Research, 1-8.
  5. Foster-Hunt, T., Parush, A., Ellis, J., Thomas, M., & Rashotte, J. (2015). Information Structure and Organization in Change of Shift Reports: An Observational Study of Nursing Hand-offs in Paediatric Intensive Care Unit. Intensive and Critical Care Nursing, 155-164.
  6. Using Frontline Staff to Improve Hand-offs. (2011). Hospital Peer Review, 17-18.
  7. Powell, S. M., & Hohenhaus, S. M. (2006). Multidisciplinary Team Trainng and the Art of Communication. Clinical Pediatric Emergency Medicine, 238-240.
  8. Farnan, J. M., Paro, J. A., Rodriguez, R. M., Reddy, S. T., Horwitz, L. I., Johnson, J. K., & Arora, V. M. (2009). Hand-off Education and Evaluation: Piloting the Observed Simulated Hand-off Experience (OSHE). Journal of General Internal Medicine, 129-134.
  9. Gregory, B. A. (2006). Standardizing Hand-Off Processes. AORN Journal, 1059-1061.
  10. Chang, V. Y., Arora, V. M., Lev-Ari, S., D’Arcy, M., & Keysar, B. (2010). Interns Overestimate the Effectiveness of Their Hand-off Communication. Pediatrics, 491-496.
  11. Yu, M., Yuol Lee, H., Sherwood, G., & Kim, E. (2017). Nurses’ Handoff and Patient Safety Culture in Perinatal Care Units. Journal of Clinical Nursing, 1442-1450.

Courtney Shrader is regulatory and quality systems program manager-transplant at UW Health in Madison, Wisconsin.

For more resources on Patient Safety, visit Patient Safety Matters.