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Back to Basics Ninth in a Series
Applying Evidence-Based Information
to Improve Hand-Off Communication
in Perioperative Services
By Alecia Cooper, RN, BS, MBA, CNOR
There are three very significant hand-offs that occur in
perioperative services for each patient who undergoes a
surgical procedure. The first one is from the pre-operative
patient care area to the holding room staff. The second one is
from the OR team to OR team members. The third one is from
the OR team to the post-anesthesia care team.
There are also additional hand-offs that result for data gathered
within each unit or area, depending upon information gath-
ered during assessment periods. There can be hand-offs from
holding room staff to anesthesia and the assigned circulator
as well as from circulator to circulator when being relieved for
breaks, lunch and at shift change. The last hand-off occurs
when the PACU nurse hands off to the post-op caregiver.
18 The OR Connection
Obviously, there are many opportunities to gather and
communicate critical information that can affect and improve
patient care, prevent injuries and medical errors and ensure
that your patient has the safest and highest-quality surgi-
cal outcomes.
Adverse events during surgery
The list of what can go wrong during a surgical experience is
long and intimidating. Foreign bodies, mislabeled pathology
specimens, operative fires, transfusion and medication errors
and wrong site, wrong procedure, wrong person surgery are
just some of the preventable hazards associated with surgery.1
Adverse events occur more often in surgery than in any other
specialty, and disproportionately greater harm results from
surgical errors.2
In the surgical setting, a premium is placed on efficiency.
There are strict schedules that must be kept despite constant
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interruptions from emergencies, add-ons, delays and compli-
cations. Time becomes a barrier to communication.2 Rushing
the hand-off can lead to small, yet critical mistakes that can
ultimately harm patients.2
Example: A patient who has been in an accident and requires
surgery also has a severe shoulder sprain. However, the staff
members who transfer the patient to preoperative holding
forget to mention this, so no one else – including the OR,
anesthesia, PACU or the floor – is aware of the shoulder
sprain. Throughout the care, nurses repeatedly manipulate
the patientʼs arm during repositioning, causing distress to the
patient and worsening the patientʼs injury.2
National Patient Safety Goal 2E
According to the Joint Commission, communication issues are
the leading factor in root causes of sentinel events.3 For this
reason, the National Patient Safety Goal 2E (NPSG.02.05.01)
was added in 2006. This goal reads as follows: “The [organi-
zation] implements a standardized approach to hand-off com-
munications, including an opportunity to ask and respond to
questions.”3 The elements of performance that are measured
by the Joint Commission in an organizationʼs hand-off
process include3:
Aligning practice with policy to improve patient care 19
Patient Safety
1. Interactive communication that allows for the opportunity
for questioning between the giver and receiver of
patient information.
2. Up-to-date information regarding the patientʼs condition,
care, treatment, medications, services and any recent
or anticipated changes.
3. A method to verify the received information, including
repeat-back or read-back techniques.
4. An opportunity for the receiver of the hand-off information
to review relevant patient historical data, which may include
previous care, treatment or services.
5. Interruptions during hand-offs are limited to minimize
the possibility that information fails to be conveyed or
is forgotten.
The goal further states that an organization should implement
a standardized approach to hand-off communication. Is your
process standardized?
Standardizing hand-off communication
Hand-off communication is defined as the “transfer of infor-
mation (along with authority and responsibility) during transi-
tions in care across the continuum for the purpose of ensuring
the continuity and safety of the patientʼs care.”4 It is the inter-
active delivery of accurate and current information about a
patient exchanged from one provider/caregiver to another. To
improve the reliability of workflows accomplishing their desired
goals, and to reduce the risk to patient safety, researchers
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recommend structured communications and clear agree-
ments about roles and responsibilities in a hand-off.5
A clear barrier to hand-off communication is the sheer number
of individuals involved in the care of surgical patients. In a
recent study, it was revealed that the typical surgical patient
sees an average of 26.6 health professionals during their
hospital stay, compared with the mean of 17.8 health profes-
sionals seen by medical patients.2 Therefore a standardized
process for hand-off communication becomes critical in peri-
operative services to ensure that communication is thorough
and complete among all of the perioperative team members.
Choosing a standardized hand-off method and tool
Healthcare providers have looked at other high-risk, high-
stakes industries such as aviation, aerospace, nuclear power
and the military for new approaches that can be applied to
healthcare hand-offs.2 Organizations have also used the Six
Sigma methodology framework to try and better understand
the process for hand-off communication.6 The development
of a standardized hand-off communications tool is a dynamic
process that allows continued opportunities for improving the
delivery of patient care.4 AORN has developed a Perioperative
AORNʼs nine recommendations for standardized hand-off policy development4
Recommendation One
Leadership should respond to the Joint Commission man-
date to improve hand-offs by initiating a program within each
facility, setting the priority and identifying the timeline.
Recommendation Two
Consider using structured tools that can facilitate consis-
tency in communication exchanges. Examples include, but
are not limited to, the “I PASS THE BATON,” “I-SBAR,”
“PACE” or the “Five Ps.” Each mnemonic is developed to
guide medical hand-offs and optimize information transfer.
Recommendation Three
When implementing training and process changes, use a
broad definition for hand-offs to include most care transitions
and information handling across the continuum of care.
Recommendation Four
Use a system, checklist, template or mnemonic that includes
updated information, recent changes in condition or circum-
stances and any anticipated changes or aspects of care that
need to be observed or watched closely.
Recommendation Five
Redesign the hand-off and shift change processes to pro-
tect against unnecessary interruptions, and allocate suffi-
cient time to the process.
20 The OR Connection
Patient “Hand-Off” Tool Kit that includes nine recommenda-
tions for standardized hand-off policy development.4
Popular hand-off communication systems
Here are four widely used hand-off communication systems:
• “I PASS the BATON” (Introduction, Patient, Assessment,
Situation, Safety Concerns, Background, Actions, Timing,
Ownership, Next)
• “I-SBAR” (Introduction, Situation, Background, Assessment,
Recommendation)
• “PACE” (Patient/Problem, Assessment/Actions, Continuing
[treatments]/Changes, Evaluation)
• “Five Ps” (Patient, Plan, Purpose, Problem, Precautions,
Physician [assigned to coordinate])
All four systems are effective as long as there is adherence
to the following rules4:
1. Conduct the hand-off face-to-face.
2. Be certain that the hand-off is two-way, with both participants
taking joint responsibility for ensuring accurate
communication.
3. Use verbal and written means of communication.
4. Give as much time as necessary to ensure accurate
communication.
Recommendation Six
Design methods that facilitate instruction on and implemen-
tation of effective communication and teamwork skills, as
provided in TeamSTEPPS, which verify information transfer
with closed-loop communication tools (including check-back,
read-back, call-out, etc.) for transferring important informa-
tion, such as critical actions, medication doses and urgent
actions.
Recommendation Seven
To meet this requirement, charts, written information and
reports/results should be available for review (as appropri-
ate) by the oncoming provider(s).
Recommendation Eight
While developing hand-off policies and protocols, include a
clear statement of how and when responsibility is transferred
during healthcare transitions.
Recommendation Nine
Teach and practice communication using established clear,
common language among care providers during hand-offs.
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10 barriers to effective hand-offs
1. Lack of education at nursing and medical schools
2. Healthcare system that historically has supported
individual autonomy and performance
3. Lack of engagement of patients and families in the
care process
4. Resistance to change among staff
5. Lack of time for providers to devote to handoffs
6. Problems in the physical setting, including
background noise and interruptions
7. Language barriers between clinicians and between
the clinician and the patient. Itʼs also important for
clinicians to avoid abbreviations and ambiguous
terminology
8. Failures in mode of communication, such as fax
machine or email or the inability to locate the
patient record
9. Lack of definitive scientific research and data to
identify accepted hand-off best practices
10. Lack of financial resources to implement
standardized hand-off processes
TeamSTEPPS
TeamSTEPPS (Team Strategies and Tools to Enhance Per-
formance and Patient Safety) is an evidence-based team-
training curriculum used by the Department of Defense (DoD).
It was developed by the Agency for Healthcare Research and
Quality (AHRQ).
The DoD Patient Safety Program extended permission to
AORN to customize its existing materials with a focus on
perioperative settings. This is what was used in the develop-
ment of AORNʼs tool kit. The TeamSTEPPS program is an op-
portunity for the surgical team to diminish the risk of error and
improve patient outcomes by creating a structure to support
standardized hand-offs and improve communications during
care transistions.4 Within this kit are numerous tools,
mnemonics and strategies to be used as templates. The
AORN tool kit is available for free and can be downloaded
from www.aorn.org.
One healthcare organization utilizing the TeamSTEPPS
curriculum developed a team hand-off model. To minimize
interruptions and distractions during the hand-off process, this
organization modified a concept championed by the aviation
industry – the “sterile cockpit.” In response to the increasing
number of commercial airline accidents involving the cockpit
Aligning practice with policy to improve patient care 21
10 tips for effective hand-offs
1. Allow for face-to-face hand-offs whenever possible.
2. Ensure two-way communication during the
hand-off process.
3. Allow as much time as necessary for hand-offs.
4. Use both verbal and written means
of communication.
5. Conduct hand-offs at the patient bedside whenever
possible. Involve patients and families in the hand-off
process. Provide clear information at discharge.
6. Involve staff in the development of hand-off
standards.
7. Incorporate communication techniques, such as
SBAR, in the handoff process Require a verification
process to ensure that information is both received
and understood.
8. In addition to information exchange, hand-offs should
clearly outline the transfer of patient responsibility
from one provider to another.
9. Use available technology, such as the electronic
medical record, to streamline the exchange of timely,
accurate information.
10. Monitor use and effectiveness of the hand-off.
Seek feedback from staff.
crewʼs attention being diverted from more critical tasks, the
Federal Aviation Administration enacted regulations to prohibit
crew members from performing nonessential duties or activities
(including conversation) while the aircraft is involved in the
phases of flight most commonly associated with error: taxi,
takeoff and landing.6
This healthcare organization interpreted the sterile cockpit
concept for the clinical setting during the verbal transfer of
patient information. Specifically, only patient-specific conver-
sation or urgent clinical interruptions were permitted to occur
during the hand-off process. They measured their perform-
ance improvement after implementing the system and found
they were able to reduce hand-off turnaround time from 15.3
minutes to 9.6 minutes.
Formula 1 hand-offs
Another healthcare organization has initiated a new hand-off
process modeled after routine pit stops in racing, which typically
take less than 10 seconds. Each crew member has a specific
job that they know very well. The crew is prepared down to
the smallest detail. Safety is the number one concern because
the consequences of errors can be life-threatening for both
driver and crew. In contrast to pit stops, hand-offs can be
chaotic events involving multiple simultaneous conversations.
Continued on Page 23
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This organization utilized a human factors expert along with
members of the medical staff to study the unique maneuvers
of Formula 1 pit crews. They witnessed many behaviors that
they then applied to patient hand-offs following surgery. Before
the hand-off, the surgical team notifies the receiving care-
givers of any specific equipment that the patient will need so
that there is no scrambling to get it set up. The equipment can
be ready and waiting upon arrival.
When the patient arrives, there is a routine process that is
standardized and takes place in the same order every time.
First, all lines and tubes are untangled and reconnected qui-
etly and efficiently. Then, the team ensures that the patientʼs
condition is stable before the report begins. The final phase is
the report, which utilizes a handover checklist and surgeonʼs
summary. This occurs without distraction from transfer activi-
ties or competing conversations because the receiving team
is able to give their full attention to the transferring team as
the report is given. The hand-off is smooth, efficient and –
most important – safe.2
Battling lost data in nursing hand-offs
In a study done by Pothier, Monteiro et al, the hand-off of 12
simulated patients was observed over five consecutive hand-
off cycles. Three hand-off styles were used and the amount of
data loss was recorded for each style. The purely verbal hand-
off style resulted in the loss of all data after three cycles. A
note-taking style resulted in only 31 percent of data being
transferred correctly after five cycles. When a printed form
was included with the verbal hand-off, data loss was minimal.
The authors recommend that nursing and medical staff
include a printed data sheet as part of the hand-off process.4
AORN describes the preoperative brief as a powerful tool to
“bring the entire OR team onto the same page”; remove
incorrect assumptions; clarify the intended plan and contin-
gency plans; obtain key information from surgeons, anesthe-
sia providers, circulating nurses and surgical technologists or
scrub nurses that enhances patient care safety and quality
and develop counter-strategies for avoiding common pitfalls,
errors and complications.4
the recipient is prepared to mentally process. Because of this,
many organizations have developed structured communica-
tion techniques such as checklists and read-back techniques.6
The use of a checklist serves two purposes. It ensures that
critical information necessary for patient care is not over-
looked and it provides a consistent order in which infor-
mation is communicated.
These tools serve to address those unique issues or critical
pieces of information related to continuity of patient care
between specialty areas.4 The hand-off checklist or docu-
mentation tool will help ensure a standardized method for
everyone to use. Although checklists can enhance memory,
longer lists might not be as effective. A checklistʼs content and
design must be prudent and strategic to gain its desired results.
When providing the hand-off communication, remember these
important communication techniques to ensure that there is
two-way interaction:
• Get the personʼs attention
• Make eye contact
• Face the person
• Use the personʼs name
• Express concern
• Use a standardized communication technique
• Use a standardized communication tool/checklist
• Re-assert as necessary
• Escalate if necessary
Transitions in care are prime targets for improved patient
safety efforts. There are several strategies that have been
developed in high-reliability organizations that can be applied
to health care and have been successfully implemented with
positive results. For a sample hand-off policy and procedure
as well as checklists and other tools from Trinity Medical
Center in Rock Island, IL, please refer to Pages 82-83
and 85-86 in the Forms & Tools section. Trinity has been
recognized by the Joint Commission as a model for
hand-off communication.

AORN recommends using four different Pre-Operative Intra-Operative Post-Operative Discharge Brief/Home
hand-off briefs, the Pre-Op Brief, Hand- Pre-Op Brief Hand-Off Post-Op Discharge
Off Briefs for Continuity, Post-Op Brief Briefs for Brief Brief
and Discharge Brief. The diagram to the Continuity
right displays the operating room briefs “Bring the OR Nurse-nurse Anesth to To the patient and
from the OR to discharge home. team onto the Anesth-anesth PACU nurse family for home
same page” by Tech-tech to inpatient care or home
Forms and checklists stating the plan provider health nurse with
To facilitate an individualʼs comprehen- clear diagnosis
sion of what is communicated, informa- and post-op plan
tion must be organized in a format that

Aligning practice with policy to improve patient care 23

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Topics for hand-off checklists

Anesthesia provider may report: Perioperative nurse may report:
• Patient name, gender, age, procedure, physician • Baseline patient assessment
• History of present illness • Positioning during procedure
• History of chronic illness • Skin prep
• Relevant pre-op lab tests • ESU pad placement and removal assessment
• Type of anesthesia administered • Use of special equipment (laser, endoscope)
• Patient response to anesthesia agents • Intraoperative irrigation fluids
• Duration of anesthesia • Administration of medications or dyes from
• Reversal agents surgical field
• Narcotics • Implants, transplants, explants
• Antibiotics • Dressing
• Fluid replacement and type (I & O) • Drains, stents, catheters
• Invasive monitoring line • Sensory or motor limitations
• Vital signs • Prosthesis presence
• Allergies • Pressure ulcer risk assessment
• Other conditions • Other pertinent patient information
• Medications given • Information about the family or others waiting
• Complications related to the procedure for the patient
• Orders

Surgeon may report: Be sure to complete the CE

• Immediate orders credit crossword puzzle on
• Diagnostic tests for PACU
Page 26!
• Interventions needed in PACU

References
1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg.
2006;243: 628-635.
2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at:
http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008.
3 The Joint Commission. National Patient Safety Goals: History Tracking Report 2009-
2008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafe-
tyGoals/09_hap_npsgs.htm. Accessed November 4, 2008.
4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at:
http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed No-
vember 4, 2008.
5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evi-
dence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008.
6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Hand-
off Communication in High-Risk Patients. Available at: http://www.ahrq.gov/down-
loads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008

24 The OR Connection