Handoffs can pose risks to patients.
Nurses throughout a children's hospital understood patient handoffs differently, resulting in handoff
errors (failures) across departments.
Lean principles were used to modify and implement the ISHAPED (Introduction, Story, History, Assessment, Plan, Error Prevention, and Dialogue) tool.
The team implemented a modified ISHAPED (m-ISHAPED) tool to align the content shared and the expectations for interdepartmental handoff
Improvements were seen in reported patient safety events from 6.84 to 1.57 per 100 patient days (P
< .001) and nurse satisfaction from 81.1% to 90.6% (P
A standardized process for interdepartmental nursing handoff
was successfully implemented.