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CE Article: Two facilities share creative handoff strategies*

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Learning objectives: After reading this article, you will be able to:
      1. Recognize the crucial importance of successful patient handoffs
      2. Identify two alternatives to SBAR
      3. Describe two creative ways to teach staff about new facility

Finding a handoff technique that works for your facility requires staff input, trial and error, and a willingness to be imaginative. Two facilities embraced the need to enhance staff communication and developed a handoff that worked for what they needed.

A new way at Warren Hospital

Instead of creating another form for staff members to fill out, administrators at Warren Hospital in Phillipsburg, NJ, thought that developing a simple mental tool to help nurses and transporters during the handoff process would be a better option. The Four Ps, which stands for patient name, place, procedure, and pertinent information, was developed in place of other tools, like the more popular SBAR, and has been implemented in the medical-surgical units (med-surg). "We thought it was more of a mental process that [transporters and nurses] could put in place for themselves," says Mary Mislonka, director of materials management. "The Four Ps are easy to remember. It isn't anything that they have to start jotting down."

Targeting nurse-to-transporter handoff

Started as a performance improvement project, the Four Ps is a means of standardizing the nurse-transporter handoff. When transporters arrive to move a patient, they are prompted to use the following Four Ps as a way to remember what to ask the nurse:

  • Whether it is the correct Patient
  • What Place the patient is going to
  • What Procedure the patient will undergo
  • Any other Pertinent information a transporter may need to know about a patient

"This helped put a consistent process to it," says Gail Newton, RN, MSN, director of cardiac services. "The transporters knew what they were going to ask and the nurses knew what they were going to be asked, so it helped facilitate this happening and cut down on the time that was spent waiting."

Newton says she and her development group--which included herself, Mary Mislonka, coordinator Matt Mislonka, and some transporters and nurses-wanted to keep their method for handoffs simple. The group realized that the Joint Commission's (formerly JCAHO) National Patient Safety Goal #2 regarding handoffs does not require the use of a form. They also realized that many forms created for transport were already ignored and underutilized. For answers to frequently asked questions on Patient Safety Goal #2 (Communication), click here.

Testing the process

Before Warren Hospital implemented the Four Ps in fall 2006, it trialed the method on one med-surg unit of more than 30 beds for two months. Two of the nurses who helped develop the process were on that unit, so overall there was an increased acceptance by the rest of the nursing staff. Mary Mislonka created laminated cards that explained the Four Ps for transporters on this trial unit. That helped the transporters and nurses get used to the process.

Increasing staff member feedback

Overall feedback has been positive from the nursing and transport staffs, says Mary Mislonka. Prior to implementing this process, patients would often ask the transporters where they were going--if it was for a test, what the test was like, or perhaps a more detailed description of what the test was for.

"They were always asking us, and we just kind of stood there with this blank look on our faces because we don't know what the x-ray is for," coordinator Matt Mislonka says. "Now, it is less time-consuming for us as long as we have that contact with the nurse before. It makes our job a little easier."

Matt Mislonka also points out that the Four Ps process increases communication flow at the other end of a handoff. If one transporter delivers a patient for tests and, using the Four Ps process, gives all pertinent information, that information can be repeated back to a different transporter who might pick up the patient after the tests have been taken.

Staff members like the increased consistency in handoff reports now, Newton says.

Smooth handoffs at Sioux Falls Surgical Center

Staff members at Sioux Falls (SD) Surgical Center have been using an alternative acronym called PANDA to decrease communication errors during handoffs. The acronym was developed after the facility took a look at the number of communication errors it was committing.

"We had done a review in 2006 of our patient errors and we could see that 11% of our errors were due to communication in some way or another," says quality specialist Marla Hassler, RN. "We wanted to be proactive rather than reactive and look at this a little further."

Developing an alternative to SBAR

Hassler coordinated a work group of representatives from each department involved in patient care, beginning with the front office. Also included were representatives from the PACU, OR, anesthesia, and recovery care. The group first flowcharted communication information from each department's standpoint and then had to come to a consensus about what departmental information was essential to a patient's care. Last came the challenge of developing a concise, standardized approach.

"Each member was given the challenge of coming up with a specific handoff," Hassler says. "I did give them the acronyms that were already out there, like SBAR and others, and none of us liked any of those."

Northwest Community Hospital in Arlington, Ill., built on SBAR at its facility and settled on SHARED. Read about that experience here.

An OR nurse came up with the PANDA acronym, which stands for:
P = Patient, procedure, physician
A = Assessment
N = Need to know
D = Drains and dressings
A = Allergies

The rest of the committee thought PANDA was a good acronym, because not only was it an original handoff idea, but it lent itself to a visual campaign.

"All of the staff members in our facility wear pins with pandas on them, so if any patients were to ask what the pins are for, we could say, 'Well, it's a reminder for us to promote patient safety,' which is kind of a warm, fuzzy way of saying it," Hassler says.

The work group first piloted PANDA as a handoff reminder on the PACU. The group received positive feedback and, at that point, decided to make its use hospital-wide. It was decided that the best way to use the handoff was to create an index card-sized PANDA explanation to include in the three-ring binders that hold patient charts.

Implementing a new handoff technique also required staff education. Hassler says group members took the approach back to their own departments and had inservices about the topic.

To see how another hospital, Brigham and Women's in Boston, handles its nurse-to-nurse handoffs, click here.

Source: Briefings on Patient Safety, December, 2007.

1. "FAQ's for the Joint Commission's 2007 National Patient Safety Goals."
Available at
2. "New Hand Off Policy Ensures Communication, Patient Safety." Available at
3. "Sharing Information at Transfers: Proven Technique to Aid Handoff Communications." Available at

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