Improving handoff communications in critical care

Haim Berkenstadt, Yael Haviv, Atalia Tuval, Yael Shemesh, Alexander Megrill, Amir Perry, Orit Rubin, Amitai Ziv

Research output: Contribution to journalArticlepeer-review

111 Scopus citations


Background: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. Methods: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training. Results: The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator. Conclusions: Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.

Original languageEnglish
Pages (from-to)158-162
Number of pages5
Issue number1
StatePublished - Jul 2008
Externally publishedYes


  • Miscellaneous
  • Practice
  • Training in internal medicine


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