Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Communication breakdowns during clinical patient handoffs are a critical patient safety issue in the Emergency Department (ED). These incidents undermine care continuity and increase the risk of sentinel events (Atinga et al., 2024). This toolkit presents an evidence-based improvement plan to reduce communication-related errors during transitions in care. The goal is to train nurses and interdisciplinary teams with tools that facilitate timely and organized data exchange, supporting clinical decision-making. Key interventions include the execution of patient handoff devices. The plan aims to create a safety culture in which staff feel confident and supported in delivering accurate patient updates. Research from PubMed, CINAHL, and Google Scholar guided the development of this plan. The CRAAP test was applied to ensure all sources were current, relevant, and credible. These peer-reviewed studies provided insights into enhancing communication practices and minimizing the risk of missed clinical evidence.
Browning, L., Khan, Leggat, S., & Boyd, J. H. (2025). The impact of electronic medical record implementation on the process and outcomes of nursing handover: A rapid evidence assessment. Journal of Nursing Management, 2025(15). https://doi.org/10.1155/jonm/5585723
This paper explores a Rapid Evidence Assessment (REA) that evaluates the influence of Electronic Medical Record (EMR) execution on nursing handover processes. The article was chosen due to the increasing integration of EMRs in clinical settings and their potential to enhance and delay communication during patient handoff. EMRs were used to verify information; 50% of nurses found EMR-generated printouts cumbersome, and 69% reported they contained irrelevant data. Nurses were dissatisfied with EMR-based handovers, stating that the systems were poorly designed and didn’t support their thinking.
They felt that the systems were developed without their input. Digital literacy was a barrier, with older, more experienced nurses less likely to find EMRs easy to use. However, some studies highlighted successful adoption where nurse engagement and co-design were prioritized, such as a quality improvement project led by a clinical nurse specialist. These findings can guide nurses, inform policy, and improve handover tools by emphasizing usability and situational awareness. This paper is crucial in shaping safer and effective EMR-mediated handover practices.
Chien, L. J., Slade, D., Dahm, M. R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S., & Thornton, A. (2022). Improving patient‐centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing, 78(5), 1413–1430. https://doi.org/10.1111/jan.15110
This resource emphasizes a linguistic and ethnographic review that aimed to enhance standards in clinical handoffs by tackling communication encounters and the administrative culture. The authors recorded 16 patient handoffs and three multidisciplinary team huddles before the intervention. A tailored intervention was implemented, consisting of education using ISBAR and CARE (Connect, Ask, Respond, Empathise) procedures. The article was selected due to its innovative approach to enhancing handover efficiency, as well as its emphasis on patient involvement and nurse empowerment.
Post-intervention results showed improvements, including consistent bedside handovers, increased patient participation, and improved use of structured communication protocols. Nurses reported that patients now clearly knew the nurse responsible for their care and had more opportunities to contribute information, correct errors, and ask questions. This paper is valuable for nurses in improving standard of patient handoff by integrating interactive communication protocols and promoting a culture of accountability and collaboration. This paper is important as it demonstrates how a communication-focused intervention can reduce hospital-acquired complications.
Galli, A., Andreoli, E., Pallua, F., Silvestri, I., Manenti, Dignani, L., Contucci, S., & Menditto, V. G. (2025). Improvement of nursing handover in emergency department: A prospective observational cohort study. Discover Health Systems, 4(1). https://doi.org/10.1007/s44250-025-00180-3
This article investigated a prospective observational review evaluating the efficiency of a consistent patient handoff device. The authors aimed to determine whether this planned communication approach improves the precision of data exchange during shift changes. The paper was selected for its relevance in addressing patient safety risks associated with communication errors in high-pressure environments.
After executing the ISBAR-based framework, the median Nursing Handover Assessment Score (NHAS) increased from 78% (IQR: 66.7–100%) to 84.6% (IQR: 74.2–100%) (p < 0.001), with marked improvements in critical indicators such as comorbidity reporting (from 59.7% to 80.8%). These findings can director nurses in promoting continuity of care, preventing information loss, and ensuring timely treatment decisions. This paper is vital as it validates that standardization benefits both junior and senior nurses equally and improves efficiency without increasing workload. However, limitations include a single-site design, non-random sampling, the potential Hawthorne effect, and a lack of validation for the handover tool.
Alcalá, P. J., Garau, A. D., Fernández, M. J. S., Reina, C. C., Pernas, P. D., Hernández, A. A., & Marrodán, B. R. (2023). Safe handoff practices and improvement of communication in different paediatric settings. Anales de Pediatría, 99(3), 185–194. https://doi.org/10.1016/j.anpede.2023.08.008
This resource examined patient handoff practices across various pediatric care settings. The authors highlight that inadequate data management during patient handoffs accounts for over 70% of healthcare-related adverse events. The article was preferred due to its relevance in improving patient safety through structured communication strategies like SBAR, I-PASS, and IDEAS. The paper is useful nurses in using standardized tools to enhance communication, prevent medication errors, and ensure continuity of care. This paper identifies key risk factors contributing to handoff errors, such as poor safety culture, lack of communication training, fragmented records, and distractions. It highlights interventions like bedside handoffs, closed-loop communication, simulation-based training, and individualized care plans.
Atinga, R. A., Gmaligan, M. N., Ayawine, A., & Yambah, J. K. (2024). “It’s the patient that suffers from poor communication”: Analysing communication gaps and associated consequences in handover events from nurses’ experiences. SSM – Qualitative Research in Health, 6, 100482. https://doi.org/10.1016/j.ssmqr.2024.100482
This study presents a qualitative investigation conducted by the authors in two Ghanaian referral hospitals to explore communication gaps among nursing shift teams and their effect on patient handoffs. The article was selected for its significance in highlighting the overlooked issue of clinical handover challenges in low- and middle-income countries, where standardized communication protocols are lacking.
The authors gathered data through site observations, uncovering key drivers of communication breakdown, including poor documentation, interpersonal conflicts, lateness to duty, and the use of unstandardized communication tools. This paper is important for nurses and healthcare leaders to develop organized communication strategies and handover training. Notably, 17 patients per shift nurse (well above recommended levels) and a deficiency of consistent patient handoffs protocols contributed to the problem. The paper identifies behavioral, organizational, and cultural factors that adversely impact patient care and offers policy direction.
Haliq, S. A., & AlShammari, T. (2025). Communication handover barriers among nurses and paramedics in emergency care settings. BioMed Central Nursing, 24(1), 634. https://doi.org/10.1186/s12912-025-03286-4
This resource demonstrated a comparative study on patient handoff barriers observed by staff in ED. The authors conducted a investigation using a revised Nursing Handover Perspectives Questionnaire with 219 respondents (87.6% response rate). The article is relevant to emergency care communication and its contribution to improving handover quality and patient safety. Nurses were expected to recognize lost vital signs (p = 0.006).
They also valued structured tools like ISBAR for communication clarity (p = 0.014) and patient safety (p = 0.019). This article is valuable for nurses and healthcare leaders in designing targeted interventions, such as simulation-based training and electronic handover tools. This paper is important as it reveals systemic gaps, such as a lack of formal patient handoffs training for paramedics and variability in protocol adherence. Despite demographic differences, no correlation was found between personal characteristics and perceptions of communication barriers.
McCarthy, S., Motala, A., Lawson, E., & Shekelle, P. G. (2025). Use of structured handoff protocols for within-hospital unit transitions: A systematic review from making healthcare safer IV. British Medical Journal Quality & Safety, 4, 1–11. https://doi.org/10.1136/bmjqs-2024-018385
This paper outlines the implication of patient handoffs approaches in refining patient care during within-unit clinical care transitions. The article focuses on protocols such as SBAR and I-PASS. SBAR showed low-certainty evidence for improving patient safety, while I-PASS demonstrated moderate-certainty evidence in reducing medical errors across 10 studies. This paper guides nurses in adopting structured message tools to decrease mistakes, recover care continuity, and enhance teamwork in nurse-to-nurse and nurse-to-physician interactions. For instance, 31% of misconduct rights and over 1,700 demises in 5 years were linked to communication failures.
This paper is important because it highlights evidence-based strategies to address a long-recognized safety gap. However, limitations include the scarcity of randomized trials, potential publication bias, and limited generalizability beyond academic hospitals. Additional investigation is needed to assess the efficiency of these protocols in diverse clinical settings, including rural and community hospitals. Incorporating training programs and consistent evaluation methods can help overcome variability in implementation. Despite its limitations, the article reinforces individual care and supports the adoption of patient handoff protocols across healthcare systems.
Toumi, D., Dhouib, W., Zouari, I., Ghadhab, I., Gara, M., & Zoukar, O. (2024). The SBAR tool for communication and patient safety in gynaecology and obstetrics: A Tunisian pilot study. Biomed Central Medical Education, 24(1). https://doi.org/10.1186/s12909-024-05210-x
This study was conducted by the authors in the obstetrics and gynecology department, evaluating the information and approaches regarding the SBAR communication tool. The article is important in addressing communication failures. It is the primary contributor to adverse events in healthcare. The study revealed that 89% of the 62 participating interdisciplinary teams had low awareness of SBAR. These findings can guide nurses and leaders in recognizing the importance of organized patient handoffs to enhance clarity, minimize adverse outcomes, and promote interprofessional teamwork.
However, this paper is important because it highlights limitations such as its single-center focus, small sample size, and lack of long-term knowledge retention assessment. The paper highlights the necessity for targeted exercise programs to recover SBAR familiarity among healthcare professionals. Expanding the research to multiple centers could enhance the generalizability of the findings. Future studies should also assess the sustained impact of SBAR training on clinical outcomes and communication efficiency.
Vega, M. F., George, M., Day, L., Owens, K., Sweeney, C., Chau, S., Escalante, C., & Bodurka, D. (2024). Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a comprehensive cancer center. The Joint Commission Journal on Quality and Patient Safety, 50(8), 560–568. https://doi.org/10.1016/j.jcjq.2024.03.004
This study investigates the execution of a patient handoff tool, I-PASS to address collaboration gaps. The authors describe how a multidisciplinary team comprising members from 22 hospital services, including nurses, trainees, faculty, EHR staff, and training specialists, collaborated to identify barriers to effective handoffs and implement an evidence-based solution. The article was chosen due to its organization-wide impact and relevance to improving patient safety through structured communication.
Training in the I-PASS tool was provided to all relevant staff either online or in person. As a result, adherence to the written I-PASS tool significantly increased from 42% in 2019 to 71% in 2022 (p < 0.05), and handoff favorability scores in the institution-wide protection rose from 39% in 2018 to 58% in 2022. These findings can inform nurses on the adoption of patient handoff tools to enhance communication and safety.
Desmedt, M., Ulenaers, D., Grosemans, J., Hellings, J., & Bergs, J. (2021). Clinical handover and handoff in healthcare: A systematic review of systematic reviews. International Journal for Quality in Health Care, 33(1). https://doi.org/10.1093/intqhc/mzaa170
This resource explores a comprehensive review of patient handoffs practices in healthcare, highlighting its importance in ensuring patient safety. The article focuses on adverse events estimated to be the 14th leading cause of global disease burden, and the link between poor handover and patient harm, healthcare staff burnout, and increased costs. This article guides the adoption of SBAR, mnemonics, liaison roles, and simulation-based training to standardize and improve communication during transitions of care. Limitations include the lack of a universally accepted evaluation tool and limited high-quality evidence showing direct improvements in patient outcomes. Most interventions improved replacement measures, such as handover duration and user satisfaction. This paper is important as it reveals a pressing need for standardized, context-sensitive handover tools and targeted training programs.
Galatzan, B. J., Johnson, E., Judson, T., & Shan, L. (2024). Linguistic dissection of nursing handoffs: Implications for patient safety in varied‐acuity hospital settings. Journal of Clinical Nursing, 33(8), 3077–3088. https://doi.org/10.1111/jocn.17190
This resource examines a mixed-methods study that investigates how patient handoffs communication varies across hospital units with differing levels of patient acuity. The article was selected for its innovative application of linguistic analysis to address a crucial aspect of patient safety. The study found that insight and causation words, which are essential for expressing clinical reasoning, were underused compared to LIWC norms. Speech dysfluency, such as filler words, was highest in the ICU, while future-oriented language was the lowest (e.g., only 0.44% in the ICU), indicating limited anticipatory communication. ICU nurses had the highest clout but the lowest authenticity in speech. These findings are important for nurses and educators in improving the clarity, structure, and cognitive depth of handoff conversations in high-acuity units. This paper is important because it highlights how informal and unstructured language can compromise patient outcomes.
Poku, Yeye, P., Anaba, Abor, Amponsah, E., & Abuosi. (2023). Response to patient safety incidents in healthcare settings in Ghana: The role of teamwork, communication openness, and handoffs. BioMed Central Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10000-0
This article examines the occurrence and types of Patient Safety Incidents (PSIs), patient handoffs, and collaboration in staff reactions to PSIs. The authors surveyed 1,651 health workers using validated tools, revealing prevalent PSIs including medicine mistakes (30.5%), infusion reactions (24.7%), wound infections (23.3%), skin ulcers (21.4%), and patient falls (18.8%) reported at least monthly. The article was selected for its relevance in understanding how non-technical skills influence patient safety in low-resource settings. The findings showed satisfactory scores for teamwork (4.17), handovers and data exchange (3.88), and communication openness (3.86), which predicted PSI response (accounting for 28.3% of the variance).
This paper is useful for healthcare staff in implementing strategies to enhance care. The paper implications emphasize the status of regular teamwork training, patient handoff protocols, and promoting open communication. Training programs increased nurses’ knowledge, confidence, and willingness to adopt structured communication methods. This paper underscores that mandatory training on patient safety is recommended during education and licensure renewal.
Each resource in the toolkit plays a crucial role in addressing communication gaps during patient handoffs. Browning et al. (2025) conducted a REA to assess the influence of EMR execution on handoffs. The findings revealed that while EMRs supported information verification, they highlighted issues such as poor design and limited nurse involvement. Chien et al. (2022) implemented a tailored intervention that combined ISBAR and CARE protocols, resulting in more consistent bedside handovers and increased patient participation. Galli et al. (2025), examined the use of ISBAR in an emergency department and found improvement in handover completeness, with NHAS scores increasing from 77.9% to 84.7%. Alcalá et al. (2023) emphasized the importance of organized patient handoff approaches, such as SBAR and I-PASS, in pediatric settings to decrease preventable adverse events.
Atinga et al. (2024) conducted a qualitative study in Ghana, identifying major barriers such as poor documentation and interpersonal conflicts that led to diagnostic delays and treatment errors. Haliq and AlShammari (2025) compared the perceptions of nurses and paramedics in emergency settings, showing that nurses valued structured tools like ISBAR, while paramedics reported more frequent interruptions and a lack of formal training. Moreover, McCarthy et al. (2025) reviewed structured handoff protocols and found that SBAR and I-PASS reduced communication failures, with I-PASS being linked to a decrease in adverse events, although SBAR showed limited implementation fidelity.
Toumi et al. (2024) evaluated SBAR training and found that post-training satisfaction was high, with 80.7% of participants indicating an intention to implement the tool. Vega et al. (2024) stated that a multidisciplinary team at a cancer center increased I-PASS adherence, resulting in improved safety culture scores. Desmedt et al. (2021) synthesized systematic reviews and found structured patient handoffs reduced preventable adverse events but noted a lack of standardized outcome measures. Poku et al. (2023) found that teamwork, handoffs, and collaboration predicted patient safety incident responses, highlighting the importance of non-technical skills. Finally, Galatzan et al. (2024) employed linguistic analysis to demonstrate that ICU handovers lacked future-oriented language and cognitive clarity, characterized by high dysfluency, highlighting the need for structured training and standardization.
Communication gaps during nursing handovers addressed through the practice of organized patient handoffs strategies, virtual devices, and targeted training. Implementing standardized tools like ISBAR, SBAR, and I-PASS enhanced the clarity and constancy of patient handoffs, leading to reductions in communication errors and preventable adverse events. Training programs increased nurses’ knowledge, confidence, and willingness to adopt structured communication methods.
Alcalá, P. J., Garau, A. D., Fernández, M. J. S., Reina, C. C., Pernas, P. D., Hernández, A. A., & Marrodán, B. R. (2023). Safe handoff practices and improvement of communication in different paediatric settings. Anales de Pediatría, 99(3), 185–194. https://doi.org/10.1016/j.anpede.2023.08.008
Atinga, R. A., Gmaligan, M. N., Ayawine, A., & Yambah, J. K. (2024). “It’s the patient that suffers from poor communication”: Analysing communication gaps and associated consequences in handover events from nurses’ experiences. SSM – Qualitative Research in Health, 6, 100482. https://doi.org/10.1016/j.ssmqr.2024.100482
Browning, L., Khan, Leggat, S., & Boyd, J. H. (2025). The impact of electronic medical record implementation on the process and outcomes of nursing handover: A rapid evidence assessment. Journal of Nursing Management, 2025(15). https://doi.org/10.1155/jonm/5585723
Chien, L. J., Slade, D., Dahm, M. R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S., & Thornton, A. (2022). Improving patient‐centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing, 78(5), 1413–1430. https://doi.org/10.1111/jan.15110
Desmedt, M., Ulenaers, D., Grosemans, J., Hellings, J., & Bergs, J. (2021). Clinical handover and handoff in healthcare: A systematic review of systematic reviews. International Journal for Quality in Health Care, 33(1). https://doi.org/10.1093/intqhc/mzaa170
Galatzan, B. J., Johnson, E., Judson, T., & Shan, L. (2024). Linguistic dissection of nursing handoffs: Implications for patient safety in varied‐acuity hospital settings. Journal of Clinical Nursing, 33(8), 3077–3088. https://doi.org/10.1111/jocn.17190
Galli, A., Andreoli, E., Pallua, F., Silvestri, I., Manenti, Dignani, L., Contucci, S., & Menditto, V. G. (2025). Improvement of nursing handover in emergency department: A prospective observational cohort study. Discover Health Systems, 4(1). https://doi.org/10.1007/s44250-025-00180-3
Haliq, S. A., & AlShammari, T. (2025). Communication handover barriers among nurses and paramedics in emergency care settings. BioMed Central Nursing, 24(1), 634. https://doi.org/10.1186/s12912-025-03286-4
McCarthy, S., Motala, A., Lawson, E., & Shekelle, P. G. (2025). Use of structured handoff protocols for within-hospital unit transitions: A systematic review from making healthcare safer IV. British Medical Journal Quality & Safety, 4, 1–11. https://doi.org/10.1136/bmjqs-2024-018385
Poku, Yeye, P., Anaba, Abor, Amponsah, E., & Abuosi. (2023). Response to patient safety incidents in healthcare settings in Ghana: The role of teamwork, communication openness, and handoffs. BioMed Central Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10000-0
Toumi, D., Dhouib, W., Zouari, I., Ghadhab, I., Gara, M., & Zoukar, O. (2024). The SBAR tool for communication and patient safety in gynaecology and obstetrics: A Tunisian pilot study. Biomed Central Medical Education, 24(1). https://doi.org/10.1186/s12909-024-05210-x
Vega, M. F., George, M., Day, L., Owens, K., Sweeney, C., Chau, S., Escalante, C., & Bodurka, D. (2024). Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a comprehensive cancer center. The Joint Commission Journal on Quality and Patient Safety, 50(8), 560–568. https://doi.org/10.1016/j.jcjq.2024.03.004
