title: Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.
abstract: 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.
authors.affiliation: The Israel Center for Medical Simulation, Sheba Medical Center, Tel Hashomer Ramat Gan 52621, Israel. berken@netvision.net.il
authors.forename: Haim
authors.initials: H
authors.lastname: Berkenstadt
authors.forename: Yael
authors.initials: Y
authors.lastname: Haviv
authors.forename: Atalia
authors.initials: A
authors.lastname: Tuval
authors.forename: Yael
authors.initials: Y
authors.lastname: Shemesh
authors.forename: Alexander
authors.initials: A
authors.lastname: Megrill
authors.forename: Amir
authors.initials: A
authors.lastname: Perry
authors.forename: Orit
authors.initials: O
authors.lastname: Rubin
authors.forename: Amitai
authors.initials: A
authors.lastname: Ziv
mesh_terms: D003266:Continuity of Patient Care / Q000592:standards; D003422:Critical Care / Q000379:methods / Q000592:standards*; D006747:Hospital Communication Systems / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D008505:Medical Staff, Hospital / Q000193:education*; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000592:standards; D010348:Patient Care Team / Q000592:standards*; D016544:Patient Simulation; D010360:Patient Transfer / Q000379:methods / Q000592:standards; D012189:Retrospective Studies; D012308:Risk Management / Q000379:methods / Q000592:standards*