This article is from the Journal for Healthcare Quality (JHQ). The full article is available to NAHQ members. Join NAHQ or log in to access.

Authors: Neville, Brett; Miltner, Rebecca S.; Shirey, Maria R.



Effective communication among healthcare teams is essential for ensuring handoff-related safety and quality care outcomes.


The aim of this project was to improve patient safety through the reduction of communication-related errors on an acute hemodialysis unit (AHU) in an academic medical center. A target was set to reduce by 50 percent the communication-related errors using strategies to improve teamwork and communication.


Acute hemodialysis unit team members attended Clinical Team Training (CTT) informational sessions on teamwork and communication. A structured handoff tool was implemented in the AHU to improve nurse communication and reduce communication-related patient safety events. Descriptive statistics and comparison of means were conducted to assess the differences between preimplementation and postimplementation audit and safety event data.


There was a statistically significant difference between the preintervention and postintervention groups of handoff tool usage and completion as well as a consistent decrease in handoff-related safety events after implementation.


Findings suggest that CTT and a structured handoff tool used to guide nurse-to-nurse care transitions lead to a reduction in communication-related safety events during handoffs in an AHU.

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