Handoff communication: using failure modes and effects analysis to improve the transition in care process

Qual Manag Health Care. Apr-Jun 2011;20(2):103-9. doi: 10.1097/QMH.0b013e3182136f58.


Handoff communication is a high-risk process that causes errors that lead to ineffective care delivery and patient safety breaches. A failure modes and effects analysis was utilized to proactively evaluate handoff through a risk priority scoring process that focused the improvement plan on communication from shift to shift and between units. The electronic medical record was utilized to standardize the handoff tool in SBAR (situation, background, assessment, and recommendation) format for both nurses and patient care technicians. Key concepts of Jean Watson's caring model were incorporated into workflow, along with team huddles, to hardwire team communication and patient-centered care. Changes to the handoff process were piloted on the telemetry unit then launched on remaining nursing units over time. Data targeting patient satisfaction and nurse-sensitive outcomes were collected pre and post-implementation with notable gains. Sustaining change in light of care-related variables is a challenge leadership, quality, and patient care teams are committed to achieving.

MeSH terms

  • Communication*
  • Continuity of Patient Care / organization & administration*
  • Humans
  • Medical Records Systems, Computerized
  • Patient Care Team / organization & administration*
  • Patient Satisfaction
  • Quality Improvement / organization & administration*
  • Risk Factors