Negative consequences of inadequate nursing handoffs: Best practices need to be identified

Apr 8 2010

A systematic review of nursing handoff literature found that minimal research has been done to identify best practices, despite well-known negative consequences of inadequate nursing handoffs. The article was published in the April issue of the American Journal of Nursing (AJN) (www.ajnonline.com). AJN, the leading voice of nursing since 1900, is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals and institutions in medicine, nursing, allied health, and pharmacy.

"Nursing handoffs occur when shifts change two or three times daily, seven days a week, yet despite the frequency of these events, there are few evidence-based standardized procedures to ensure that communication is managed effectively," said Lee Ann Riesenberg, director of Medical Education Research and Outcomes, Academic Affairs, Christiana Care Health System, Newark, Delaware and research assistant professor, Jefferson School of Population Health, Thomas Jefferson University. "Errors in communication give rise to substantial clinical morbidity and mortality and, therefore, must be addressed."

In 2005, the Joint Commission found, after reviewing a decade's worth of data, that "breakdowns in communication" were implicated in two-thirds of all types of sentinel events. Furthermore, a 2009 Agency for Healthcare Research and Quality survey found that almost half (49%) of hospital staff respondents reported that important patient care information is lost during shift changes.

"This study underscores the need for more research in this area," said Maureen Shawn Kennedy, MA, RN, editorial director and interim editor-in-chief of AJN. "Even though the Joint Commission is now requiring the standardization of patient handoffs, there's little evidence to indicate how to most effectively accomplish this process."

SOURCE American Journal of Nursing