Date of Award

Summer 2022

Project Type


College or School




Program or Major

Direct Entry Master's in Nursing

Degree Name

Master of Science

First Advisor

Elizabeth Evans


INTRODUCTION: Inadequate handoff communication is a contributing factor in sentinel events and adverse patient outcomes. Research has shown that the use of a standardized handoff tool can improve quality of handoff communication. This quality improvement (QI) project sought to standardize handoff and reduce the risk of adverse patient outcomes by utilizing the I-PASS handoff tool available in the electronic medical record (EMR).

AIM: The aim of this quality improvement project was to improve the accuracy of nurse-to-nurse patient handoffs.

METHODS: The outcomes measured by the post-intervention survey were the number of reported handoffs received with omissions, the percentage of staff using the standardized report tool regularly, and staff satisfaction with the standardized handoff tool. The primary measures were the percentage of handoffs with omissions as reported on the post-intervention surveys. A quantitative analysis of post-intervention survey responses was performed using descriptive statistical analyses. The frequency of reported handoffs with omissions and the associated method of handoff were obtained from the post-intervention survey responses using a tick and tally method.

RESULTS: The I-PASS handoff tool post-educational feedback survey results were as follows (1) 100% of the nursing staff either strongly agreed or agreed that they were confident in their ability to give an organized and concise handoff report; (2) 84% of respondents agreed or strongly agreed that the I-PASS tool could be beneficial in increasing patient safety on the unit (3) 83% of nursing staff either agreed or strongly agreed that utilizing the handoff tool could be beneficial in keeping report on topic; (4) 100% of respondents either agreed or strongly agreed that they liked the idea of using an I-PASS tool that is linked to the patients EMR; and (5) 100% of respondents agreed that I-PASS could be a beneficial tool for relaying patient handoffs and that SBAR would be a good way to communicate patient status changes.

DISCUSSION: The purpose of this QI project was to minimize the risk of adverse patient outcomes caused by inadequate communication. Due to conflicting priorities, the outcomes of this QI project deviated from the previously outlined aims. The updated aim of the final project was to provide staff education related to the I-PASS tool while obtaining feedback from the nursing staff on their perceptions of usefulness of integration into practice. The key finding of this project was that the staff nurses agree that I-PASS could be useful in several ways if integrated into practice.