Quality & Patient Safety

Refocusing on handoffs can reduce safety events, improve patient safety

Patient Safety Monitor, September 1, 2010

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After The Joint Commission released its National Patient Safety Goal concerning handoff communication in 2005, staff at Children’s Healthcare of Atlanta (Children’s) spent plenty of time and effort convincing staff that the issue was an important one. As a result, the hospital standardized its handoff approach. 

Since then, Children’s has implemented electronic documentation and computerized physician order entry systems, and it had to reexamine the issue of transfer of care in relation to these advances.

“It was, ‘How did those two things impact our process, and had we done everything to mitigate the risks?’ ” says Robin Warnick, RN, BSN, clinical patient safety coordinator at Children’s. 

Warnick has been leading the effort with a team of caregivers to improve upon existing shift-to-shift, unit-to-unit, and surgical services transfers of care since March. She and a clinical leader decided to focus on these handoffs due to the health system’s occurrence reports, which showed that handoffs were a major source of errors.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

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