Comprehensive Nurse-to-Nurse Hand Offs for Optimal Patient Outcomes
By: Heather Kooiker, DNP, MSN, RN, CNL, CNOR, CRNFA, CNMAP
Published: 6/13/2025
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How often have you given a hand-off report to the next nurse, and it seems as if they aren’t listening or don’t value the report? Have you ever asked yourself “Why am I wasting my time listening to a report when the nurse is not telling me anything that I need to know about caring for this patient?” In perioperative nursing, we often run into this problem as there are three distinct phases of care (ie, preoperative, intraoperative, postoperative). Across those phases of care, there are nurses who do not understand the responsibilities of the nurse to whom they are reporting. This can cause frustration and an inefficient use of time when time is a factor.
For example, the preoperative nurse reports to the OR nurse that “The patient is nice and the IV is in the right hand.” The OR nurse can see that the IV is in the right hand, and in the big picture, the niceness of the patient does not affect care decisions. Another prime example is when the OR nurse reports to the postoperative nurse that “The patient went under anesthesia with no problems and the case went well.”
An effective hand off includes information that the receiving nurse needs to know to safely take over the patient’s care. For example, the preoperative nurse should report the patient’s allergies, visual or hearing impairment, history of violence during anesthesia emergence, location of tattoos, and jewelry that was unable to be removed; medications given; any positioning concerns and risk for pressure injury; and any other health history that may impact the safety of the patient during surgery.
The OR circulating room nurse’s report to the postanesthesia care nurse should include things like patient position and duration, pressure injury risk and risk mitigation, medications delivered from the sterile field, tourniquet use, blood loss, any visual or hearing impairment, and any unexpected events that may have occurred during surgery. The postanesthesia care nurse should report to the inpatient unit personnel if the patient is admitted. This report would include surgical position, torniquet use, visual or hearing impairment, medications delivered, airway, pain, and most recent vital sign trends.
These types of reports are given often and become redundant, which can lead to nurses no longer listening to report, but rather saying “Yes, okay” just to move on with caring for the patient. However, a concise, complete report is critical. For example, rushed, nonspecific reports have resulted in medication errors when a hearing impairment was omitted from the report. Reports that do not include patient risks for pressure injury can result in pressure injury. Redundancy can often lead to nurse errors and patient injury.
An exploratory study involving a survey of health professionals found that 40% believed that adverse events (eg, delays in treatment, medication errors) were a possible consequence of ineffective hand offs.¹ In another study, poor communication was tied to 22% of clinical management incidents at a metropolitan hospital.² Authors of a report released in 2016 found that, in US hospitals, communication errors were a factor in an estimated 30% of all malpractice claims, totaling $1.7 billion in malpractice costs over five years and resulting in 1,744 deaths.³ In 2017, The Joint Commission issued a sentinel event alert, which provides advice to senders and receivers of hand-off communication.4 The Joint Commission also has developed a tool, “8 Tips for High-quality Hand-offs” that includes the following information:
- Determine critical information that needs to be communicated.
- Standardize communication tools and methods.
- Don’t rely on electronic or paper communications alone; face-to-face communication is recommended when possible.
- Combine information from multiple sources and communicate it at one time.
- Ensure the receiver gets the pertinent information.
- Conduct face-to-face hand offs in a “zone of silence” that is free from non-emergency interruptions.
- Include all team members as needed and, when appropriate, the patient and family.
- Don’t rely on electronic health records alone but utilize them to enhance information acquisition.5
New perioperative nurses with little work experience may have difficulties speaking up, especially when it comes to the nurse-to-nurse hand off to a seasoned nurse.6 The pressure to move on to the next task or next patient can be overwhelming and cut short the hand-off experience. When nurses are willing to ask questions and ask for missing information at the hand off, it enhances the nurse’s credibility with the other team members7 and helps to keep the patient safe.
The AORN “Guideline for team communication”8 is an excellent resource to develop your communication strategy to ensure that your patients have the best outcomes. According to the guideline, “promoting respectful behaviors among team members facilitates effective communication and teamwork and encourages individuals to speak up when a variance may lead to an unsafe outcome.”8(p1088) If difficulties occur with speaking up, it helps to refer to best practice. Simply ask the team member who is giving pushback, “Do you want to deliver best practice today?” This question often realigns the team and brings awareness back to best practice. Caring for patients through their surgical journey is a big job—families and loved ones trust us and believe that evidence-based care will be delivered. So, speak up and continue to ask questions until you have the knowledge you need to take care of the patients under your watch.
References
Manias E, Geddes F, Watson B, Jones D, Della P. Perspectives of clinical handover processes: a multi-site survey across different health professionals. J Clin Nurs. 2016;25(1–2):80-91. doi: 10.1111/jocn.12986.
Tran DT, Johnson M. Classifying nursing errors in clinical management within an Australian hospital. Int Nurs Rev. 2010;57(4):454-462. doi: 10.1111/j.1466-7657.2010.00846.x
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, Massachusetts: CRICO Strategies; 2016.
The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. September 12, 2017;(58). Accessed October 7, 2024. https://www.jointcommission.org/-/media/tjc/newsletters/sea-58-hand-off-comm-9-6-17-final2.pdf
8 tips for high-quality hand-offs. The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_8_steps_hand_off_infographic_2018pdf.pdf. Accessed October 7, 2024.
Kee K, de Jong D. Factors influencing newly graduated registered nurses’ voice behaviour: an interview study. J Nurs Manag. 2022;30(7):3189-3199. https://doi.org/10.1111/jonm.13742
Nembhard IM, Labao I, Savage S. Breaking the silence: determinants of voice for quality improvement in hospitals. Health Care Manage Rev. 2015;40(3):225-236. doi: 10.1097/HMR.0000000000000028
Guideline for team communication. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;2024:1085-1120.
