Date of Graduation

Fall 12-12-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



Background. Ineffective patient handoff can result in poor nurse communication, increasing the likelihood of adverse events including medication errors and documentation errors.

Context/Problem. In one 20-bed ICU unit in a northern California community hospital, 48 patient handoffs were observed over 2 weeks. Only 29% occurred at the patient’s bedside; 39.5% used a standardized handoff tool; and 54% included the patient and/or family. This indicated concerning quality gaps in the unit’s ICU patient handoff processes.

Intervention. The project intervention consisted of an introductory and two follow-up teaching sessions on handoff processes and implementing the I PUT PATIENTS FIRST handoff tool.

Measures. Metrics include a Likert-scale survey to assess nurse perceptions of the handoff process and post-implementation observation of 96 handoffs to evaluate the intervention’s impact on 3 handoff domains: location (bedside), patient/family involvement, and use of the I PUT PATIENTS FIRST tool.

Results. Due to current hospital Covid-19 pandemic restrictions, the intervention is on hold until conditions allow change projects to resume. However, the project team anticipates ≥ 25% improvement in each handoff domain and ≥ 50% improvement in nurse perception.

Conclusions. Definitive conclusions cannot be drawn until after the project has been fully implemented and evaluated (after the Covid-19 pandemic). However, the project team expects that implementing evidence-based handoff practices will result in stronger nurse knowledge exchange processes in the ICU.

Keywords: nursing handoff, nurse knowledge exchange, standardized handoff, handoff barriers.

Available for download on Thursday, July 27, 2023

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