30-Second Head-to-Toe Tool in Pediatric Nursing

Cultivating Safety in Handoff Communication

Debbie Popovich, MSN, CPNP


Pediatr Nurs. 2011;37(2):55-60. 

In This Article

Communication During Handoffs: Root Cause of Error

Following an Institute of Medicine (IOM) report of an unprecedented number of preventable medical errors in U.S. hospitals (IOM Committee on the Quality of Health Care in America, 2001), widespread national attention was focused on improvement of patient safety and quality of care. As part of a groundswell effort to reduce errors, the Joint Commission (formerly Joint Commission for Accreditation of Healthcare Organizations [JCAHO]) has for more than 15 years evaluated reportable medical errors and stratified root causes from which recommendations for improvement have been made. With more than 4800 sentinel events analyzed, the Joint Commission identified communication as the top contributing factor to medical error, with handoffs playing a "role in an estimated 80% of serious preventable adverse events" (The Joint Commission, 2010a, b).

Based on the review and recommendations from the 2006 Sentinel Event Advisory Group, the Joint Commission implemented the National Patient Safety Goals, with the most recent revision in January 2011 (The Joint Commission, 2011). Goal 2 focuses on improved communication effectiveness among caregivers because ineffective communication was cited as the most frequent root cause of sentinel events. Goal 2 calls for communication that is timely, accurate, completely unambiguous, and understood by the recipient. The expectation is that these improvements will reduce error and result in improved patient safety.

Effective communication and handoff responsibility is a fundamental component of nursing practice and clinical nursing education. It is essential to cultivate a culture of safety in nursing students' routines that will continue throughout their careers. At the time of transferring care from shift to shift or from nurse to student nurse, careful attention to details must be communicated. Various techniques to enhance safety during these transfers have been reported in the literature. One particular method involves a systematic review of information being transferred (Elm, 2004). This is done by the nurse coming on who performs a routine baseline assessment immediately following report to confirm consistency in communication during the handoff and conditions associated with safety of the patient.


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