Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk

Chest. 2008 Jul;134(1):158-62. doi: 10.1378/chest.08-0914.


Background: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff.

Methods: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training.

Results: The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator.

Conclusions: Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.

MeSH terms

  • Continuity of Patient Care / standards
  • Critical Care / methods
  • Critical Care / standards*
  • Hospital Communication Systems / standards*
  • Humans
  • Medical Errors / prevention & control
  • Medical Staff, Hospital / education*
  • Outcome Assessment, Health Care / methods
  • Outcome Assessment, Health Care / standards
  • Patient Care Team / standards*
  • Patient Simulation*
  • Patient Transfer / methods
  • Patient Transfer / standards
  • Retrospective Studies
  • Risk Management / methods
  • Risk Management / standards*