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

Critical Nature of Handoffs

According to Streitenberger and colleagues (2006), handoffs increase risks for vulnerable hospitalized patients and even more so for children, given their physiologic differences and reduced ability to advocate for themselves. Handoffs also occur at busy times with multiple distractions and time constraints. Despite these factors, improved safety of handoff practices has only recently been addressed with evidence-based techniques (Benson, Rippin-Sisler, Jabusch, & Keast, 2007; Pothier, Monterio, Mooktiar, & Shaw, 2005).

Given the high degree of patient safety risks and consequences for errors, important lessons may be learned from another area of research in which handoff practices are critical – Space Shuttle Mission Control. Here, the goal of shift change handover (handoff) is to preserve consistency in the flow of all processes and activities monitored by flight controllers. In a study by Patterson and Woods (2001), a total of 21 handoff communication and coordination strategies were directly observed at times of personnel change. Patterson, Roth, Woods, Chow, and Gomes (2004) studied strategies employed during successful handoffs in four settings with high consequences for failure: a) NASA Johnson Space Center, b) a nuclear power generation plant, c) a railroad dispatch center, and d) an ambulance dispatch center. Among objectives related to improving handoff efficiency and effectiveness, one strategy included requiring the incoming person to assess the current status of the environment or system. See Table 1 for strategies related to nursing handoffs.


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