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Use structured communication tools (SBAR or I-PASS) consistently across shifts (Gross, Salas, & Weaver, 2025).
Incorporate teach-back and closed-loop communication to confirm accuracy (Rhudy et al., 2022).
Mitigate barriers: address noise, interruptions, and fatigue with protected overlap time and leadership support (Huff et al., 2023).
Continuous auditing and feedback sustain improvements and reduce drift back to old habits (Gross et al., 2025).
Agency for Healthcare Research and Quality. (2020). Handoffs and signouts. Patient Safety Network (PSNet). https://psnet.ahrq.gov/primer/handoffs-and-signouts
The Joint Commission. (2017). Sentinel event alert 58: Inadequate hand-off communication. The Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/
World Health Organization. (2007). Communication during patient hand-overs: Patient safety solutions (Vol. 1, Solution 3). World Health Organization. https://apps.who.int/patientsafety/solutions/patientsafety/PSSolution3.pdf
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