Date of Graduation

Winter 12-16-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Danijela Pavlic, DNP, RN, CNL


Handoff, or transition in care, is known to be a danger point in the patient care process for a long time. Ineffective communication during handoff is one of the most common identified cause of catastrophic or sentinel events in hospitals (The Joint Commission, 2015). Emergency department (ED) to in-patient unit handoff is particularly vulnerable to medical errors due to high workload, time constraints, different approaches to patient care, and lack of established relationships between care providers (Ong & Coiera, 2011; Hilligoss & Cohen, 2012).

The purpose of this project was to examine and review a current process of ED to in-patient unit handoff report, to foresee possible process improvement in favor of patient care quality and safety as well as to measure nurses’ satisfaction with current communication of care in one of the hospitals in the Bay Area. A comprehensive assessment of the organization, direct observations of the interunit handoff process as well as nursing staff interviews were conducted to establish a baseline understanding of the current state of the process at the hospital.

A total of 75 Registered nurses from ED and four internal medicine units were interviewed in a course of three weeks and a total of 12 interunit handoffs were observed. A few issues in structure, process, and outcomes of handoffs were identified, such as difference in unit culture, lack of teamwork and understanding between units, lack of knowledge of available tools, as well as operational failures. After thorough review of published literature on current evidence best practices in interunit handoff, a few potential interventions were identified to improve the process. One of them is a modified ED Summary Report form based on SBAR format. The form will provide a framework for communication, along with that, it will potentially eliminate redundancy in current practice and confusion between the nurses. It will also potentially increase patient safety and nurse satisfaction.

Included in

Nursing Commons