Spotlight on How Structured Hand-off Communication Reduces Preventable Harm

Two Examples of How Structured Hand-off Communication Reduces Preventable Harm

As healthcare has evolved and become more specialized, patients are likely to encounter more handoffs than just a few generations ago. Ineffective handoffs can contribute to gaps and failures in patient safety, including medication errors, wrong-site surgery, and patient deaths.[1] It’s estimated that 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.[2] This month, we will highlight two different hospitals approach to implementing Actionable Patient Safety Solutions (APSS) Challenge #6 and optimizing Hand-off Communications.

Hand-off communications (HOC) must occur whenever care of a patient is transferred from one individual or care team to another. Accurate, effective and complete HOC are vital for patient safety. When HOC information is absent, incomplete, erroneous or delayed, serious patient harm can occur.

UCI Health’s Implementation of I-PASS

“At UCI Health (California), we have seen the need to improve hand-off communications and have been working on it in a focused way for three years,” explains Dr. William C. Wilson, MD, MA, Chief Medical Officer at UCI Health.

Through a collaboration between physicians and nurses, the hospital looked for a way they could create a handoff tool within the electronic medical record (EMR). In November 2017, they adopted the I-PASS tool and embedded it within their EMR (Figure 1).

Figure 1: I-PASS is a mnemonic used to standardize HOC

  • I – Illness Severity
  • P – Patient Summary
  • A- Action List
  • S – Situation Awareness and Contingency Planning
  • S – Synthesis by Receiver

“Before [implementing I-PASS] every person and every department did their handoffs in different ways. One person might write their instructions on a scrap of paper, another might do a verbal handoff. What we like and why we implemented I-PASS is because it is a structured handoff. If you do things in a structured way, we believe we will have better outcomes,” says Dr. Wilson.

While UCI Health hasn’t documented quantitative improvements yet, use of I-PASS has been proven to reduce medical errors. In a study published in the New England Journal of Medicine, implementation of I-PASS handoffs decreased medical error rate by 23% from the pre-intervention period to the post-intervention period and the rate of preventable adverse events decreased by 30%.  While the rate of non-preventable adverse events did not change significantly, site level analyses showed significant error reductions at six of nine sites.[3]

Parrish Medical Center Implements the PSMF’s HOC APSS

At Parrish Medical Center (Titusville, Florida), they’ve utilized the APSS to improve HOC and create their own process to address their specific concerns. The hospital emphasizes a data-centered approach and worked with its leadership and handoff communications team to design their own handoff process which measurably improves outcomes.

“When an organization really commits to a culture of safety and measures relentlessly, then they will know where they need to make changes and they will know how. It won’t be guesswork or based on anecdotal evidence,” explains Edwin Loftin, RN, MBA, NEA-BC, Chief Nursing Officer at Parrish Medical Center.

Like UCI Health, Loftin and the team at Parrish Medical Center created structured handoffs. The hospital used the checklists in the Patient Safety Movement APSS and built a process around it. The goal of the new handoff process was twofold:

  • Zero harm in transitions from the medical surgical unit to ED
  • Implement person to person handover, including the person in the bed.

The hospital also used their EMR as a means to help capture transitions in care and instructions.

“We had experienced a number of patient harm events related to HOC and wanted to find a measurable way to improve. In designing this new process, we created a checklist, utilized the electronic medical record and decided that we wanted all transitions in care to be person to person. We felt it was important to include the person at the center of this care, namely the patient, as well as the nurses,” explains Loftin.

The process was implemented May 6, 2018 and in just four weeks has demonstrated remarkable results.

Prior to the change, Parrish Medical Center recorded 48 events of patient harm in 1.5 years whether that was medication error, delay in care, etc. Since the implementation of the new handoff process, the hospital has had zero harm events in 600 transitions.

The new handoff process has also had additional benefits, including a 35% decrease in time of transition whether that is transitioning a room or implementing care as well as increased patient satisfaction.

The hospital plans to release the final results of their implementation in August.

“Almost every hospital does handoffs uniquely but it tends to be different according to where the transition is occurring. In our case, we plan to implement this same handoff process across the organization, in every department,” explains Loftin.


[1] Friesen MA, White SV, Byers JF. Handoffs: Implications for Nurses. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 34. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2649/

[2] Clutter—Part, C. (2012). Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications. Joint Commission Perspectives.

[3] https://www.nejm.org/doi/pdf/10.1056/NEJMsa1405556