Date of Award/Publication


Document Type


Degree Name

M.S. in Advanced Practice Nursing

First Supervisor

Tara L. Sacco



Background: Adverse patient events have been linked to communication errors during handoff. The Joint Commission has estimated that 65% of adverse patient events are associated with issues in communication. This, coupled with mandated electronic medical record (EMR) adoption in 2009, has complicated the implementation of effective handoffs. Many EMR systems are ill equipped to provide effective handoff tools, leading to staff non-compliance and a system of varied handoff procedures.

Purpose: To determine the barriers to nurses utilization of the EMR based handoff tool in the pediatric intensive care unit (PICU).

Methods: This study was a longitudinal pre-post analysis design, aimed at highlighting nursing staff likes and dislikes of the current EMR based handoff tool in the PICU. Using the pre-test data, a quality improvement (QI) project in the form of an in-service that provided handoff tool “cheat sheets,” was implemented to improve usability of the handoff tool and communication during change of shift report. A post-project survey was issued two months after the implementation of the QI project, to re-evaluate staff perceptions of the handoff tool/change of shift report. Pre and post hand-off tool use data was provided by unit management.

Results: The results and implications of this study are confidential protected information with the collaborating institution. The analysis and presentation of the results as well as the implications for this study was disseminated to the supervising St. John Fisher faculty and the collaborating institution and as was found to meet accepted guidelines for successful completion of the project for the purposes of completing degree requirements.

Conclusion: Current handoff tool literature shows that staff will willingly use handoff tools that are user friendly and well integrated into the EMR, but will abandon the use of tools that are not. Improving handoff tool use in the PICU could lead to improved communication, organization, and time spent giving report; thus impacting patient safety by avoiding adverse events related to communication errors. Future research and QI projects should focus on how to engage staff to be more compliant with actually using the handoff tool.

Included in

Nursing Commons