Date of Award


Document Type

Open Access Dissertation


College of Nursing

First Advisor

Stephanie Burgess


One of the most important times for the delivery of patient care occurs during the change of shift handoff between professional nurses. This complex interchange of information and responsibility carries with it distinct possibilities for error that can adversely affect a patient’s hospitalization, safety, and the quality of patient care outcomes (Blouin, 2011; Hilligoss & Cohen, 2011). Communication errors, including errors during shift handoff, account for more than 70% of sentinel events that occur in the provision of healthcare in the acute care setting (Federwisch, 2007; Streeter, 2010). Poorly conducted and unstructured shift handoffs are known to result in delayed or inappropriate treatment, increased length of stay (Blouin, 2011), gaps in patient care, and failures in patient safety which include medication errors, wrong site surgery, and patient death (Friesen, White & Byers, 2009). Experts in healthcare such as the Agency for Healthcare Research and Quality (AHRQ) have recommended the use of a standardized approach to shift handoffs (Hughes & Clancy, 2005) and have targeted communication as a quality-of-care indicator, with The Joint Commission (TJC) specifically requiring United States (U.S.) hospitals to implement a standardized approach to handoff communication. (Dufault, Duquette, Ehmann, Hehl, Lavin, Martin, …Willey, 2010). A synthesis of the literature was performed to answer the PICO question: “In the medical/surgical care setting, what is the best standardized process and tool for professional registered nurse shift handoffs that incorporates a bedside component and enhances patient safety?” While little

rigorous research was found, significant clinically important information was gleaned from the literature resulting in best practice recommendations. There is a great opportunity for collaboration between the research and practice doctors of nursing to continue to refine the process of RN change of shift handoffs. Keywords: handoff, bedside handoff, nursing handoff, communication, patient safety


© 2015, Nancy Rankin Ewing

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Nursing Commons