CSUDH Handoffs Discussion

COURSE – Quality and Performance Improvement in Healthcare

As we end our term, share your thoughts on your learning experience in this course.  Using at least three of the six prompts below, provide your reflections and explain how you will use your new knowledge.Please also include interesting material, videos, or articles from the current module.

  • I enjoyed ….
  • This got me thinking about …
  • I wish …
  • I learned …
  • I was surprised that …
  • I can use this by (or to) …


1. Handoff Procedures in Healthcare

A male pharmacist looking at a prescription bottle and writing on a clipboard.

Poor communication among healthcare providers can cause serious patient safety issues. Concise, pertinent communication is necessary to communicate important information.?The Situation, Background, Assessment, Recommendation Tool(SBAR)?can be used to increase clear communication among healthcare providers. Do you believe it is necessary to have a standardized approach for handoffs in healthcare? View more information on SBAR.

Another system for ensuring clear handoff communication is I-PASS. This is a mnemonic device/acronym that stands for the following, as shown in this activity.

  • I
  • P
  • A
  • S
  • S

Illness severity (Agency for Healthcare Research and Quality, 2018a, para. 5)

The focus of I-PASS is to improve patient safety rates by using standardized forms of communication amongst providers. The ultimate goal is to improve care transitions by reducing or eliminating miscommunications that can happen as one provider hands over care duties to another.

Beyond I-PASS and SBAR, there are various tools used for patient handoff communication. Some of these include: Smart Sign Out, Targeted Solutions Tool, and the Patient Handover Toolkit. A simple internet search will yield many results on these specific tools, as well as multiple others.

It is vital to remember that within the healthcare environment, there are many areas where handoffs occur. Handoffs do not only happen within the walls of a hospital. Areas and special situations to consider include, but are not limited to:

  • Ambulatory centers,
  • Nursing homes/skilled care facilities,
  • Hospitals,
  • Handoffs involving residents,
  • Handoffs with language barriers,
  • Handoffs for testing, and
  • Nursing handoffs.

To learn more about another handoff technique, and how it can impact patient safety and reduce medical errors, view the following video.

Warm Handoffs Improve Patient Safety

The AHRQ created a training scenario showcasing what a “warm handoff” looks like in a clinic setting.

2. High-Risk Hospital Departments

Three doctors in operation theater performing hand surgery.

When we speak of high-risk departments in the clinical area, does a specific department come to mind? Perhaps you or someone you know has had to visit one of these departments. There are four common high-risk departments that warrant special attention. Click through this activity to learn more.

An ambulance speeding through traffic at nighttimeEmergency medicine


These four areas within hospitals represent situations that carry the highest risk factors; these units require specific standards, guidelines, and levels of service, as they have notable areas of concern. For instance, Braithwaite, Wears, and Hollnagel (2015) discussed the practices of a British emergency department; given the high-risk nature of the unit, they state that there must be “a formal handover of emergency patients from ambulance paramedics to receiving clinicians. Staff use a structured communication checklist providing information to the nurse in charge who passes it to the bedside nurse” (p. 420). This process aims to mitigate risk, due to the highly complex and unpredictable nature of emergency departments.

After being exposed to multiple examples of medical errors throughout the material in this course, did any of these incidents, tragic situations, and the settlements related to these situations raise your awareness regarding the potential problems we have in healthcare? It is quite evident, given the dollar amounts of settlements, high-risk departments must be closely managed and assessed for improvement. Our healthcare industry must strive to deliver the highest quality services at all times.

Surgery and Anesthesia

Let us explore one of the specialty areas referenced in the slides, surgery and anesthesia. Did you ever consider that serious mistakes could be made in an operating room? Wrong-site surgery, medication errors, burns, and retention of surgical sponges or instruments are just a few. Click through each tab to learn more.

  • Never Event
  • Sentinel Events

Some generally accepted examples of a surgical never event are “surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person” (The Leapfrog Group, n.d., para. 2). These events are also considered sentinel events by the Joint Commission and warrant a thorough investigation by risk management. They have been reported to the Joint Commission since 1995.

In 2002, the initial never events list was designed; since then, the list has grown to 29 events categorized into seven areas:

  • Surgical,
  • Product or service,
  • Patient protection [patient safety],
  • Care management,
  • Environmental,
  • Radiologic, and
  • Criminal (AHRQ, 2018b).
a magnifying glass icon silhouette.

For additional information on never events/sentinel events, review the table of never events from the AHRQ.

Review the following article regarding a wrong-site surgical case. After you review the article, do you feel this mixture of problems was preventable? There are many other cases of preventable injuries in the surgical arena; documentation of many such cases is easily accessible through internet searches.

3. Root-Cause Analysis

Hand writing Reliability with a blue marker.

Many healthcare entities aspire to be?high-reliability organizations (HROs). Using Robust Process Improvement (RPI) tools are usually part of this process. According to the Joint Commission Center for Transforming Care (2019):

a book icon silhouette.

Based on its knowledge of health care and through studying the features of industries that have achieved high reliability, The Joint Commission constructed a framework that health care organizations can use to accelerate their progress toward the ultimate goal of zero harm. The framework is organized around three major domains of change:

  1. Leadership committed to the goal of zero harm.
  2. An organizational safety culture where all staff can speak up about things that would negatively impact the organization.
  3. An empowered work force that employs RPI tools to address the improvement opportunities they find and drive significant and lasting change (para. 2).

Organizations concerned with quality and safety improvement will likely utilize?root-cause analysis (RCA) to understand and analyze why mistakes and medical errors occurred. The root cause of the event is the most basic factor of why the event occurred, and, if removed, there will not be a repeat of the incident. When discussing RCA, it is important to note that Dlugacz (2017) stated, “The goal is to identify underlying problems in systems or processes rather than blame any individual for the incident” (p. 190). An RCA should provide an impartial analysis of the adverse event. Review the following video that explains general use of RCA for reviewing problems.

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