Challenge 6

Hand-off Communications

Executive Summary Checklist

Accurate and complete hand-off communications (HOC) are vital to patient safety. When HOC information is incomplete or erroneous, serious patient harm often occurs. The establishment of accurate, complete, effective HOC requires an implementation plan that includes the following actionable steps:

  • Hospital governance must become aware of this major performance gap as it exists in their own organization, and must participate in and support the following actions.
  • Establish an HOC core team that includes a strong sponsor (senior clinical leadership is recommended for this role), physician champion, nursing champion and project leader. Other members will include practicing physicians, nurses, therapists, technicians and information technology experts.
  • Define the exact roles of the sender and receiver in each category of HOC in order to make them effective and reliable.
  • Educate all hospital staff on the following principles and requirements for effective HOC:
    • HOC’s occur whenever patient care is transferred to a different caregiver, care team, hospital unit, or patient care site. Each HOC involves a “sender” and a “receiver.”
    • HOC failures occurs when (1) the “sender” omits vital patient information from his/her report, or (2) the “receiver” fails to understand or properly record vital information given by the sender.
    • A systematic, complete HOC process is similar in many ways to the pre-takeoff and pre-landing procedures used by aircraft crew. Aviation has made great progress in Quality Improvement in these procedures through the use of checklists. We will use a similar approach here.
    • We have identified seventeen different categories of HOC that commonly occur in hospitals or other care units. Each of these categories requires a specific HOC checklist. We have developed the first 6, ready to be implemented:
      • 1b – Emergency Department to Operating Room (Appendix A);
      • 2f – Hospital Unit to Home (discharge) (Appendix B);
      • 2g – Hospital Unit Shift Change (Appendix C);
      • 3b – Operating Room to Hospital Unit (Appendix D);
      • 3c – Operating Room to Home (Appendix E);
      • 4c– Hospital to Outside Care Unit (Appendix F).
  • Measure the effectiveness of current hand-off communication processes and build in to performance goals.

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.