To Improve Communication in Handoff Reports and Improve Patient Safety

This tool kit contains information that can be used to improve communication among nurses during shift change. This helps to prevent adverse events from happening and improves residents safety. 

Daily Report Sheets and EMR to Improve Communication and Resident Safety

 Jae-Kyun Ju, & Hye-Won Jeong. (2025). Effect of a Practice-Oriented Electronic Medical Record Education Program for New      Nurses. Healthcare, 13(4), 365. https://doi.org/10.3390/healthcare13040365

This study evaluated the effectiveness of a practice-oriented EMR education program that’s designed to improve new nurses’ EMR competencies. This study found it was greatly beneficial to accelerate EMR skill development that is gained through routine clinical exposure. This will improve new nurses’ preparedness, reduces stress and improves retention rates. The system helps to better facilitate interdepartmental communications and handovers. This is because information can be available at the click of a button. If you’re the nurse and are questioning anything about the resident or their condition, it’s available at your fingertips. Nurses should know how to appropriately use the EMR system so that all pertinent information can be recorded so all persons that need access can readily access this information.

Kumari, R., & Chander, S. (2024). Improving healthcare quality by unifying the American electronic medical report system: time for     change. The Egyptian Heart Journal, 76(1), 32. https://doi.org/10.1186/s43044-024-00463-9

This article discusses the improvement in efficiency, quality of care, collaboration and communication mechanisms. This review provided an analysis and evaluation of outcomes using the EMR system. Healthcare workers can easily access and update patient records which reduces healthcare costs and time required to manage information. This leads to improved patient care, increased collaboration and reduced medical errors. Using the EMR is an electronic way of documenting important information that all healthcare employees who need access to this information can retrieve at any time. This is a great tool to use so when you need to verify information or find more information about residents, its accessible.

Kaplan, H. C., Timpson, W., Meyers, J., Schierholz, E., Cohen, H., Fry, M., Zayack, D., Soll, R. F., Morrow, K. A., & Edwards, E. M.     (2023). Shift-to-shift handoffs in the NICU: lessons learned from a large scale audit. Journal of Perinatology, 43(12), 1468-                 1473. https://doi.org/10.1038/s41372-023-01724-2

This Journal article points out the fact that written handoff accompanied with verbal handoff were encouraged to use to reflect on the information needed for report. When things are written down, they're not omitted during handoff report. It was also found in this article that the use of EHR tools were effective and successfully improved accuracy of report. Between the written report the nurse has on hand and the health record that could be either available at a glance on the computer or a condensed version that's printed, it is unlikely to forget pertinent information to hand off to the next shift.

Bedside Report to Decrease Environmental Factors Affecting Handoff Report

Ghosh, M., Beverly O’Connell, Hien, T. N., Coventry, L., Towell-Barnard, A., Gallagher, O., Gullick, K., Gent, L., & Saunders, R.     (2025). Patient and Family Involvement in Nursing Bedside Handover: A Qualitative Descriptive Study of Consumer         Perceptions of Nursing Care. Nursing Reports, 15(2), 51. https://doi.org/10.3390/nursrep15020051

This qualitative descriptive study states that the aim of bedside handoff is to share, confirm and clarify clinical information and current condition by engaging residents and their families. This involves clear communication about the residents status and treatment plan to ensure continuity of care and their safety. These bedside reports should be clear, straightforward and include rich descriptions. Residents will see that bedside handover will allow nurses to communicate more effectively, ensuring that important information is accurately conveyed and understood. This will help to address immediate needs and be beneficial in anticipating potential issues and preventing complications. Bedside handover also allows the opportunity to actively participate in their own care and treatment.

Anshasi, H., & Almayasi, Z. A. (2024). Perceptions of Patients and Nurses about Bedside Nursing Handover: A Qualitative Systematic     Review and Meta-Synthesis. Nursing research and practice, 2024, 3208747. https://doi.org/10.1155/2024/3208747

This meta-synthesis review was aimed at identifying, synthesizing and evaluating the quality of primary qualitative studies on perceptions of patients and nurses about bedside nursing handover. It was found in this study that a good handover comes from good communications which comes from good communicators which includes handover, handover sheets and nursing notes. It was found that general information should be shared at the bedside. More critical information such as if the patient has STDs, cancer or any confidential health information should be discussed in private instead of at the bedside. During bedside report, this article draws attention to the fact it should stay confidential. This includes asking the resident/patient if they want family present or to leave the room. This also includes the preference in caregiver presence.

Webster, K. , Hlebichuk, J. , Jensen, L. & Zastrow, R. (2025). COASTing Through Bedside Report. Journal of Nursing Care Quality,     40 (1), 69-75. doi: 10.1097/NCQ.0000000000000802.

Bedside shift report improves patient satisfaction, peer accountability, communication and decreases safety events. To standardize communication during bedside report, the acronym COAST was developed. This acronym represents important highlights including: Code statues, oxygen, access, safety, tubes/drains to be discussed to minimize safety errors and adverse events. Bedside shift report has shown to improve patient satisfaction, quality and safety. This communication at the bedside includes a portion at the bedside with additional component either written or verbally exchanged in a location outside of the patients room. The patient also feels connected to their nurse and their care during bedside report. Handoff at the bedside allows the nurse to visualize the patient and their environment. Bedside report has shown to reduce adverse events such as falls, pressure injuries and medication errors. The SBAR is a widely used acronym that is also being applied to bedside report although it was originally thought and used for communication with providers. It was found in this study that blended bedside report with standardized communication tool focusing on safety can improve adoption of bedside report and patient safety outcomes.

Forde, Mary F. (10/2020). "Bedside handover at the change of nursing shift: A mixed‐methods study". Journal of clinical nursing     (1365-2702), 29 (19-20), p. 3731.

This mixed method study was aimed to describe the structures, process and content of bedside handover during change of shift. Comprehensive description of complexities of bedside handover provide insight into important nursing practice to support nurse education and development. Bedside shift report includes the off going nurse, the resident and the on coming nurse. The focus should be on the physical and physiological symptoms. During shift change the residents safety and continuity of care are dependent on the completeness and integrity of the information passed on from shift to shift. For this study a bedside handover tool was used based on five key areas: who should be involved, what needs to be handed over, where it should occur, when it should take place and how it should happen. The off going nurse explained to the patient they were doing handoff report, patient was introduced to nurse who would be assuming their care. Medical information was limited. During this study, handover summary document was used as a reference which included: name, date of birth, ID number, details of primary diagnosis/reason for admission, past medical history, alert such as infection prevention/fall risk/etc. Staff were attentive and focused displaying a caring attitude towards the patient. Most of the "what" that was reported was patients name, pain assessment, reason for admission and introduction to the nurse taking over their care. The style of delivery in this study was short face-to-face, verbal exchanges that occurred at fast-pace without use of medical terms so the patient could understand. This handover included the off going nurse, the on coming nurse and the patient with a focus on physical symptoms and physiological observations. This study found that bringing the nurses to the bedside is a positive move for increasing effective communication and reducing risks.

Jimmerson, J., Wright, P., Cowan, P. A., King-Jones, T., Beverly, C. J., & Curran, G. (2021). Bedside shift report: Nurses opinions     based on their experiences. Nursing open, 8(3), 1393–1405. https://doi.org/10.1002/nop2.755

This qualitative study was done to identify nurses' and nursing supervisors' experiences and opinions related to bedside shift report and appropriate content to be included at bedside and to identify barriers related to bedside shift report. It was found that bedside shift report improves satisfaction, quality and safety of residents. Bedside shift report is identified as the "gold standard" as it improves patient and family satisfaction, nursing quality and patient safety versus report given outside of the room. Patients and families can participate in the hand-off of content which is great to help the oncoming nurse put together a "whole picture". Handoff is a critical time as the off going nurse is handing over a resident and their care to the on coming nurse. Successful transfer of resident and care is needed to ensure continuity of care and prevent adverse events. During bedside shift report the nurse should include the introduction, open EMR, verbal report of "situation, background, assessment and recommendation" as mentioned previously. They should include focused assessment of patient and room including wounds, drains, IV tubes and sites, catheters, etc. The nurse should point out to the oncoming nurse any tasks that need to be done such as labs, medication administrations and inform nurse of any pending lab work so they can be watching for results. During this time, family or resident needs should also be addressed. Bedside shift report should be used to meet standards of resident/family satisfaction and to ensure the quality of care and patient safety.

Vanderzwan, K. J., Kilroy, S., Daniels, A., & Jennifer O’Rourke. (2023). Nurse-to-nurse handoff with distractors and interruptions:     An integrative review. Nurse Education in Practice, 67, 103550. https://doi.org/10.1016/j.nepr.2023.103550

This integrative literature review found that handoff distractors and interruptions are barriers to effective nurse handoffs that can potentially lead to preventable and costly medical errors. Nurse handoff is a critical process where nurses transfer patient information and responsibility of patients from one nurse to the next. Distractions and interruptions were identified as leading causes of error, errors that can put the patients safety at stake. Distractions were identified as equipment alarms, call lights and environmental noises that lead to distractions and interruptions during handoff report. In this article it is noted that the World Health Organization and Joint Commission recommend processes for structured clinical communication handoff. It was found in this article that nurses found interruptions and distractions no matter where they gave handoff report. In conclusion, it was found that distractions and interruptions can hinder patient handoff but nurses need to be trained on how to overcome these barriers starting at the pre-licensure level to take these skills with them throughout their practice.

SBAR Communication to Bridge The Gap

Kay, S., Unroe, K. T., Lieb, K. M., Kaehr, E. W., Blackburn, J., Stump, T. E., Evans, R., Klepfer, S., & Carnahan, J. L. (2022).  Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program. Journal of Applied Gerontology, 42(2), 194-204. https://doi-org.library.capella.edu/10.1177/07334648221131469 (Original work published 2023)

This article describes the importance of SBAR communication and PDSA (plan, do, study, act). The SBAR communication tool consists of Situation, Background, Assessment and Recommendation. This is a tool to help improve communication between nurses and physicians and empowers nurses to make recommendations based on clinical findings. SBAR provides the structure for a concise but detailed report to get the point across effectively without extra "fluff". Results have shown a reduction in hospital admissions, which is important in the long-term care setting as a lot of things that residents are sent to the hospital for are treatable in house. The PDSA cycle consists of Plan, Do, Study, Act. Step one is to plan/develop a procedure or policy to test a change. Step two is to "do", implement the plan. Step three, study the results and analyze results and areas needing improvement. Step four is to act, make modifications/changes to the plan and try again. This article found that the study used found SBAR to be a great tool in nursing homes when there was an acute change in a residents condition. It also was found that PDSA cycles allowed for protocol changes at successive facilities and improved overcoming barriers.

  Ashwaq, M. A., Mariam Saleh, S. A., Fatmah Saleh, S. A., Ashwaq, h. a., Khayreh, M. A., Sharifa Ali, m. a., Waiel, A. A., Aisha, A.         A., Anwar, M. K., Hadi, M. M., Mohammed, A. A., & Turki, M. K. (2024). Impact of Poor Communication among Nurses and         Internal Medicine physicians on Patient Safety: A Narrative Review with case studies. Journal of International Crisis and Risk         Communication Research, 7, 411-425. https://doi.org/10.63278/jicrcr.vi.1004

This article points out that effective communication in healthcare is cornerstone for patient safety and desired clinical outcomes stating that effective communication is a critical skill that heavily influences patient outcomes and safety. Effective communication increases patient satisfaction and adherence to treatment plans, decreases medical errors which in turn decrease adverse events and enhances quality of care. This is a systematic approach article to identify, evaluate and summarize relevant studies that identified communication barriers and strategies/interventions implemented to improve them and outcomes related to patient safety and quality of care. Collaboration between nurses and physicians where found to enhance patient outcomes. Communication barriers that were found include hierarchical structures, differences in professional training and language, time constrains and workload pressures which lead to misunderstandings, errors and compromised patient outcomes. Inadequate handoffs during shift change were also noted as critical moments where communication failures frequently occur. This leads to incomplete transfer of patient information, missed information and can cost the facility money. This article found that implementing evidence-based strategies to improve communication is crucial for patient safety and quality of care, SBAR communication is then discussed. The framework for the SBAR communication tools includes: Situation, Background, Assessment and recommendation. Situation: what is going on with the person, symptoms, Background: history, Assessment: the nurses point of view, Recommendation: any recommendations the nurse has for the resident and their condition. This approach aims to create a structured, consistent, collaborative communication environment that will reduce errors and improve patient safety and outcomes. SBAR improves clarity and efficiency of information exchange between healthcare providers.

Tyler, D. A., Feng, Z., Grabowski, D. C., Bercaw, L., Segelman, M., Khatutsky, G., Wang, J., Gasdaska, A., & Ingber, M. J. (2022).   CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons         Learned. The Milbank quarterly, 100(4), 1243–1278. https://doi.org/10.1111/1468-0009.12594

This article contains information related to this topic stating that the rates of hospitalization and emergency room visits remain high despite efforts made to reduce avoidable hospitalizations from nursing homes. This article also points out that many of these visits to the emergency room and hospitalizations are avoidable with the collaboration of nurses and physicians within the long-term care facility. Alongside this, also improving hands-on care in monitoring, assessing, and managing changes in resident condition can greatly reduce the instances of ER visits and hospitalization and reduce the cost to Medicare. This information is obtained to piece together pieces of the SBAR when communicating with other healthcare providers.