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lose track of the patient at the center of all of the activity. Inattention,
distractions and interruptions can easily derail the handoff (see
"Avoid These Communication Pitfalls").
Poor handoffs are vulnerable junctures where errors can occur.
S A F E T Y
We had to address a few communication issues that
occurred during patient handoffs at our hospital.
Perhaps you've seen them occur in your facility, too.
• Distractions. They significantly increase the
amount of time it takes to exchange information.
They can also lead to more errors occurring during the
exchange. Examples of distractions include noisy moni-
tors and equipment, other staff members conversing
nearby and interactions with the patient. Try to limit those
influences, and tell staff to focus solely on the exchange of
information during the handoff.
• Interruptions. Staff members who ask questions
unrelated to the handoff, chart clinical information as
the exchange is taking place and communicate with
members of the patient's family divert attention away
from what matters most and can result in incorrect or incomplete information being
passed along to the next level caregiver.
• Inattention. Human behavior can play a significant part in limiting the effec-
tiveness of handoffs. A fast-talking handoff-giver who doesn't provide opportunity for
the handoff-receiver to ask questions can be as bad as the distracted handoff-receiv-
er who gives the impression of being too good to need a report about the patient's
condition.
— Pegi Wasserman, RN, BSN
HANDOFF HANG-UPS
Avoid These Communication Pitfalls
z ONE THING MATTERS
Eliminate potential distractions
that can interfere with the
exchange of information.
