PATIENT SAFETY: COMMUNICATION FAILURES DURING NURSING HANDOVERS
DOI:
https://doi.org/10.71399/9f7ngz79Keywords:
Patient Safety, Communication, NursingAbstract
Communication is essential in healthcare, ensuring continuity of care and patient safety. Nursing handovers, a critical moment in this process, involves the transmission of information regarding the patient's clinical status, therapeutic plans, and care needs. Communication failures do occur and are associated with adverse events, including medication errors, falls, inaccurate diagnoses, and delayed interventions, ultimately compromising the quality of care.
Objective: To analyze the impact of communication failures during nursing handovers on patient safety.
Methodology: A systematic review of studies published between 2019 and 2024, indexed in international databases including PubMed, Scopus, SciELO, Web of Science, and ProQuest, using MeSH terms and PICO criteria. Fifteen studies were included and analyzed based on the Joanna Briggs Institute (JBI) guidelines.
Results: The findings indicated that communication failures are associated with the lack of standardization, frequent interruptions, and omission of relevant information. Structured models such as ISBAR and SBAR, as well as digital technologies and checklists, have been shown to reduce errors and enhance communication effectiveness, thereby contributing to patient safety.
Conclusions: The ISBAR and SBAR models have proven effective in minimizing communication failures during nursing handovers, supporting both patient safety and continuity of care.
References
Abdullah, B. F., Angelen Shirley, S. G., & Dioso, R. (2024). Enhancing Teamwork Through Effective Handover Practices Among Nurses in Elder Care Setting. Malaysian Journal of Nursing, 15(4), 100–108. https://doi.org/10.31674/mjn.2024.v15i04.012 DOI: https://doi.org/10.31674/mjn.2024.v15i04.0012
Abraham, J., Lopez, K. D., O’Rourke, J. & Riesenberg, L. A. (2020). Comparison of a Nurse- Nurse Handoff Mnemonic With Real-World Handoffs. Journal of Nursing Care Quality, 35(4), 336–340. https://doi.org/10.1097/NCQ.0000000000000465 DOI: https://doi.org/10.1097/NCQ.0000000000000465
Ak., E. N., Erten, E. E., Kavakli, O., & Pazar, B. (2024). Implementation and Evaluation of the SBAR Communication Model in Nursing Handover by Pediatric Surgery Nurses. Journal of PeriAnesthesia Nursing, 39(2), 1-6. https://doi.org/10.1016/j.jopan.2023.12.021 DOI: https://doi.org/10.1016/j.jopan.2023.12.021
Alexander, L., Godfrey, C. M., Khalil, H., Marnie, C., McInerney, P., Munn, Z., Peters, M. D. J., Pollock, D. & Tricco, A. C. (2020). Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis, 18(10), 2119–2126. https://doi.org/10.11124/JBIES-20-00167 DOI: https://doi.org/10.11124/JBIES-20-00167
Alizadeh-risani, A., Fotokian, Z., Khatooni, M., Mohammadkhah, F., & Pourhabib, A. (2024). Comparison of the SBAR method and modified handover model on handover quality and nurse perception in the emergency department: a quasi-experimental study. BMC Nursing, 23, 585. https://doi.org/10.1186/s12912-024-02266-4 DOI: https://doi.org/10.1186/s12912-024-02266-4
Anacleto, J., Brás, F., Guerra, A., Marques, M. C., Ruivo, M.A., & Siquenique, J. (2023). Comunicação ISBAR na Qualidade Dos Cuidados De Saúde. Revista Ibero-Americana de Saúde e Envelhecimento,9(2),30-46. http://dx.doi.org/10.60468/r.riase.2023.9(2).597.30-46
Andrade, L. A. S., Arthur, J. P., Corpolato, R. C., Mantovani, M. D. F., Mattei, A. T. & Willig, M. H. (2019). Padronização da passagem de plantão em Unidade de Terapia Intensiva Geral Adulto. Revista Brasileira de Enfermagem, 72(1), 95– 102. https://doi.org/10.1590/0034-7167-2017-0745 DOI: https://doi.org/10.1590/0034-7167-2017-0745
Arad, D., Lehmann, A., Lipschuetz, M., Regev, G. & Toren, O. (2022). Improving Patient Safety in General Hospitals Using Structured Handoffs: Outcomes From a National Project. Frontiers in Public Health, 10, 1-10. https://doi.org/10.3389/fpubh.2022.777678 DOI: https://doi.org/10.3389/fpubh.2022.777678
Atinga, R. A., Ayawine, A., Gmaligan, M. N., & Yambah, J. K. (2024). “It’s the patient that suffers from poor communication”: Analyzing communication gaps and associated consequences in handover events from nurses’ experiences. SSM – Qualitative Research in Health, 6, 1-9. https://doi.org/10.1016/j.ssmqr.2024.100482 DOI: https://doi.org/10.1016/j.ssmqr.2024.100482
Barbosa, M. R. S., Bezerra, A. L. Q., Costa, N. N., Freitas, J. S., Lima, J. C. & Silva, A. E. B.C. (2016). O retrato dos eventos adversos em uma clínica médica: análise de uma década. Revista Cogitar Enfermagem, 21(5), 1-10. https://doi.org/10.5380/ce.v21i5.45661 DOI: https://doi.org/10.5380/ce.v21i5.45661
Brown, D., Calleja, P., Lovell, T., Mitchell, M., Nielsen, S., O ́Neill, K., Powell, M. & Walsham, J. (2023). Improving the handover of complex trauma patients by implementing a standardised process. Australian Critical Care, 36, 799–805. https://doi.org/10.1016/j.aucc.2022.10.020 DOI: https://doi.org/10.1016/j.aucc.2022.10.020
Carrington, J. M. & Galatzan, B. J. (2022). Communicating Data, Information, and Knowledge in the Nursing Handoff. CIN: Computers, Informatics, Nursing, 40(1), 21–27. https://doi.org/10.1097/CIN.0000000000000806 DOI: https://doi.org/10.1097/CIN.0000000000000806
Carvalho, S. I. P. (2023). Gestão operacional da passagem de turno para a garantia da qualidade e segurança dos doentes. [Dissertação de Mestrado, Escola Superior de Enfermagem do Porto]. Repositório Científico de Acesso Aberto de Portugal. https://comum.rcaap.pt/handle/10400.26/49922
Denecke, K., Kocher, D. R., Mahendran, P. & Schmidt, T. (2019). Dynamic Pocket Card for Implementing ISBAR in Shift Handover Communication. Stud Health Technol Inform, 267, 224-229. https://doi:10.3233/SHTI190831.´ DOI: https://doi.org/10.3233/SHTI190831
Elaswarapu, R., Lipman, V., Manthorpe, J., Moriarty, J. & Norrie, C. (2020). A qualitative study of handovers at shift changeovers in five care homes for older people in England. International Journal of Older People Nursing, 15, 1-11. https://doi.org/10.1111/opn.12339 DOI: https://doi.org/10.1111/opn.12339
Foster, S. & Manser, T. (2012). The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research. Journal of the Association of American Medical Colleges, 87(8), 1105- 1124. https://doi: 10.1097/ACM.0b013e31825cfa69 DOI: https://doi.org/10.1097/ACM.0b013e31825cfa69
Galatzan, B. J., Johnson, E., Judson, T. & Shan, L. (2024). Linguistic dissection of nursing handoffs: Implications for patient safety in varied-acuity hospital settings. Journal of Clinical Nursing WILEY, 33, 3077-3088. https://doi: 10.1111/jocn.17190 DOI: https://doi.org/10.1111/jocn.17190
Johnsgaard, T., Kinn-Mikalsen, M. A., Reime, M. H. & Tangvik, L. S. (2024). Intrahospital Handovers before and after the Implementation of ISBAR Communication: A Quality Improvement Study on ICU Nurses’ Handovers to General Medical Ward Nurses. Nursing Reports, 14, 2072–2083. https://doi.org/10.3390/nursrep14030154 DOI: https://doi.org/10.3390/nursrep14030154
Organização Mundial de Saúde. (2023). Plano de ação global para a segurança do doente 2021–2030: Rumo à eliminação dos danos evitáveis nos cuidados de saúde. Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa. https://www.who.int/publications/i/item/9789240032705
Tacchini-Jacquier, N., Turini, P., Urben, P., Verloo, H. & Waele, E. (2020). Developing an Evidence-Based Nursing Handover Standard for a Multi- Site Public Hospital in Switzerland: Protocol for a Web-Based, Modified Delphi Study. JMIR Research Protocols, 9(1), 1-11. https://doi.org/10.2196/15910 DOI: https://doi.org/10.2196/15910
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