What’s New in the Patient Safety World

December 2011

AORN Perioperative Handoff Toolkit



We’ve done many columns on the problems associated with handoffs in healthcare (see the listing and links at the end of today’s column). Handoffs are perhaps the most common transactions in hospital-based healthcare and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors to 70% of all Sentinel Events in Joint Commission’s Sentinel Event database and many of those breakdowns occur during handoffs.


AORN (the Association of periOperative Registerd Nurses) has worked with the Department of Defense Patient Safety Program to develop a Perioperative Patient 'Hand-Off' Tool Kit. Though many of the principles are applicable to handoffs in any environment, these are tailored specifically for those occurring in the perioperative environment. Given that it was developed in conjunction with the DoD it is not surprising that it heavily incorporates materials from the TeamSTEPPS™ program.


The toolkit discusses the Joint Commission requirements for standardized handoff communications and stresses that handoffs should be held where there is adequate time, with minimal distraction, and allow for interactive discussion where the recipient is able to review all relevant material and has ample opportunity to ask questions. They stress the importance of using language that is clearly understood by all parties and use of “read-back”, “repeat-back” and “hear-back” to ensure that communication is understood by all parties. They also stress the importance of not only passing on information during a handoff but also passing on responsibility for care of the patient.


Structured handoff formats are discussed at length and examples of the various formats used in different hospitals are provided. These include SBAR, ISBAR, I Pass the Baton, PACE, and the 5 P’s. They do also note, as we have in the past, that a combination of verbal and written components in a handoff works better than either alone and they note the potential for use of information technology to enhance the handoff process.


These are good tools. In particular, if you are looking for a form, template or checklist to use in your perioperative handoffs you’ll probably be able to find it here.




Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS™

August 28, 2007           Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008      Hot Topic: Handoffs

November 18, 2008      Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009              Interruptions, Distractions, Inattention…Oops!

April 13, 2010              Update on Handoffs

July 12, 2011               Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011               Communication Across Professions

November 2011            Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics








AORN. Perioperative Patient 'Hand-Off' Tool Kit.















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