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Handoff Communication: Using Failure Modes and Effects Analysis to Improve the Transition in Care Process

Freitag, Michelle BSN, RN; Carroll, V. Susan MS, RN, CNE

Quality Management in Health Care: April/June 2011 - Volume 20 - Issue 2 - p 103–109
doi: 10.1097/QMH.0b013e3182136f58
Original Article

Handoff communication is a high-risk process that causes errors that lead to ineffective care delivery and patient safety breaches. A failure modes and effects analysis was utilized to proactively evaluate handoff through a risk priority scoring process that focused the improvement plan on communication from shift to shift and between units. The electronic medical record was utilized to standardize the handoff tool in SBAR (situation, background, assessment, and recommendation) format for both nurses and patient care technicians. Key concepts of Jean Watson's caring model were incorporated into workflow, along with team huddles, to hardwire team communication and patient-centered care. Changes to the handoff process were piloted on the telemetry unit then launched on remaining nursing units over time. Data targeting patient satisfaction and nurse-sensitive outcomes were collected pre and post-implementation with notable gains. Sustaining change in light of care-related variables is a challenge leadership, quality, and patient care teams are committed to achieving.

Rush Oak Park Hospital, Oak Park, Illinois.

Correspondence: V. Susan Carroll, MS, RN, CNE, Rush Oak Park Hospital, 520 S Maple Ave, Oak Park, IL 60304 (

©2011Lippincott Williams & Wilkins, Inc.