Date of Award

Summer 2024

Project Type

Thesis

College or School

CHHS

Department

Nursing

Program or Major

Nursing, DEMN

Degree Name

Master of Science

First Advisor

Pamela Kallmerten, PhD, DNP, RN, CNL

Second Advisor

Elizabeth Evans, DNP, RN, CNL

Third Advisor

Deborah Simonton, EdD, MS, RN, CNL

Abstract

Abstract

Background: Gaps in communication in the patient handoff process have been directly linked to patient safety errors and unwanted patient outcomes. The reviewed literature highlights multiple factors impacting the handoff process and unanimously conclude that a standardized handoff process is necessary in maintaining a high standard of patient safety and a minimization of safety errors.

Methods: This intervention took place in an 86-bed, acute care facility, a level III trauma center macrosystem with implementation of this project taking place in the emergency department and medical/surgical microsystems. Utilizing the Plan, Do, Study, Act framework over a total of eight weeks, nurses on emergency department and medical/surgical units were surveyed about the current state of shift handoff communication and related errors, were educated on the new implementation of the I-PASS handoff tool, implemented I-PASS handoff tool for shift report handoff for four weeks, and chart audit data was collected to assess adherence to the I-PASS tool.

Intervention: The I-PASS model was adapted from the widely used SBAR model and was embedded into the existing EHR. Both the transferring and receiving nurses were required to complete their respective portions including adding their name and telephone extensions to provide a layer of accountability. The 5x5x5 framework was specified to escalate the issue in instances of unresponsiveness by the receiving nurse.

Results: The results of the project indicated only a 33 percent adherence rate by emergency department nurses and a 6 percent adherence rate by medical/surgical nurses. Chart audit data was used to further assess barriers to adherence and resistance to change.

Conclusion: The standardized I-PASS model for patient handoff is an effective tool to reduce communication errors in many patient care settings, however, further implementations are needed in this specific microsystem to evaluate sustainability, potential implications for practice, and overall impacts on interprofessional communication.

Keywords: Patient handoff, communication, standardized, I-PASS

Download

Share

COinS