CONTINUING EDUCATION

Transfer-of-CareCommunication: Nursing BestPractices 2.1 www.aorn.org/CE

ROBIN CHARD, PhD, RN, CNOR; MARTIN A. MAKARY, MD, MPH

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours byreading this article, reviewing the purpose/goal and objectives,and completing the online Examination and Learner Evalua-tion at http://www.aorn.org/CE. A score of 70% correct on theexamination is required for credit. Participants receive feed-back on incorrect answers. Each applicant who successfullycompletes this program can immediately print a certificate ofcompletion.

Event: #15535Session: #1001Fee: Members $16.80, Nonmembers $33.60

The contact hours for this article expire October 31, 2018.Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge specific to transfer-of-care communication.

Objectives1. Explain why communication tools are needed in the peri-

operative setting.2. Identify barriers to communication.3. Describe common communication tools in use in the OR.

AccreditationAORN is accredited as a provider of continuing nursingeducation by the American Nurses Credentialing Center’sCommission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recerti-fication, as well as other CE requirements.

AORN is provider-approved by the California Board ofRegistered Nursing, Provider Number CEP 13019. Checkwith your state board of nursing for acceptance of this activityfor relicensure.

Conflict-of-Interest DisclosuresRobin Chard, PhD, RN, CNOR, and Martin A. Makary,MD, MPH, have no declared affiliations that could beperceived as posing potential conflicts of interest in the pub-lication of this article.

The behavioral objectives for this program were created byHelen Starbuck Pashley, MA, BSN, CNOR, clinical editor,with consultation from Susan Bakewell, MS, RN-BC,director, Perioperative Education. Ms Starbuck Pashley andMs Bakewell have no declared affiliations that could beperceived as posing potential conflicts of interest in thepublication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for thisarticle.

DisclaimerAORN recognizes these activities as CE for RNs. Thisrecognition does not imply that AORN or the AmericanNurses Credentialing Center approves or endorses productsmentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2015.07.009ª AORN, Inc, 2015

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Transfer-of-CareCommunication: Nursing BestPractices 2.1 www.aorn.org/CE

ROBIN CHARD, PhD, RN, CNOR; MARTIN A. MAKARY, MD, MPH

ABSTRACTThe successful and safe transfer of the patient from one phase of care to another is contingent onoptimal communication by all team members. Nurses are often in a natural leadership position toimprove safe practices during hand overs. A holistic understanding of the patient allows the periop-erative nurse the opportunity to identify issues and choose a nursing diagnosis based on key elementsof a patient’s needs and goalsdinformation that should be relayed during patient transfers. Thisarticle reviews best practices in transfer-of-care communication to enable perioperative RNs totake an active, leading role in hand-over processes. AORN J 102 (October 2015) 330-339.ª AORN, Inc,2015. http://dx.doi.org/10.1016/j.aorn.2015.07.009

Key words: transfer of care, checklists, nursing communication, hand over, time out.

Safe systems, protocols, and triggers are increasinglyrecognized as drivers of good patient outcomes. Theuse of these tools within the context of a strong

culture of teamwork has been observed to have a greaterproportional effect on patient outcomes than certain newmedications and innovative procedures. The surgical team isresponsible for the patient’s safe journey through the surgicalcare continuum because the patient is often unable to alert theteam if there is misinformation, which makes efforts to preventmistakes crucial.

Patient care is littered with many potential hazards that allmembers of the surgical team must be aware of and attempt toprevent. In some situations, safer systems need to be devel-oped, and in others, better compliance with safety tools andbest practices is needed. As a result of the necessary changeoverof health care providers throughout a patient’s stay, disconti-nuity can result during the exchange of patient information,potentially leading to medical errors. Patient transfers occur atmultiple times (eg, shift changes, relief for breaks, lunch,dinner) and during several points of care (eg, hand-overreporting among nursing units, reporting of pertinent

patient data among departments).1 The patient is morevulnerable to the incidence of error in the surgical settingthan in other settings because of the multiple hand oversthat occur throughout the preoperative, intraoperative, andpostoperative phases of care.2

One of the most critical procedures in hospitals today is thepatient hand over (ie, hand off). The successful and safetransfer of the patient during all phases of care is contingent onoptimal communication by all team members, especiallynurses, who are often in a natural position to improve safepractices. Additional factors related to transfer-of-carecommunication include the agility of established workflowsand processes that help the patient move through the system,the ability of team members to function as a team, and thelevel of support that personnel in each unit of the facilityreceive from the overall organizational system. The purpose ofthis article is to review best practices in transfer-of-carecommunication to enable perioperative RNs to take anactive, leading role in transfer-of-care communication pro-cesses. Also provided are communication tools to facilitateoptimal care transfers.

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COMMUNICATION: A CRITICALNURSING COMPETENCYUnderstanding best practices in transfer-of-care communica-tion begins with a foundation of strong communication skills.For perioperative nurses, whether they are point-of-carepractitioners, managers, or educators, effective communica-tion is a valuable skill to bring to a complex work environ-ment. Within the context of health care work environments,strong communication enables team members to ensure theoverall success of a health care organization. In the nursingcommunity, perioperative nurses are professionally andpersonally responsible for pursuing lifelong learning that in-cludes competency in individual practice and interdisciplinarycommunication. Experience in nursing skills and procedures,coupled with a commitment to developing and maintainingcommunication skills, should be emphasized in a professionalperioperative nurse’s practice, in addition to his or her com-petencies and commitment to lifelong learning.

Early in their education, nurses learn that one of their mostcrucial roles is that of patient advocate. In the perioperativeenvironment, nurses are charged with being the maincommunication conduit between the patient and the team;therefore, their contributions to the overall safety of the pa-tient experience cannot be overestimated. Perioperative nursesare in a unique position to use their communication skills tofurther the overall mission and vision of nursing, as well as thatof the professional workplace in establishing heath care sys-tems that are dedicated to quality improvement and pa-tient safety.

There is an art and scientific methodology to effective patientcommunication. Knowledge of the patient’s physiological,psychosocial, cultural, spiritual, and educational needs allowsthe perioperative nurse to provide a holistic approach to care.A holistic picture of the patient allows the perioperative nursethe opportunity to identify patient care issues that extendbeyond the medical diagnosis and planned surgical procedureand choose a nursing diagnosis based on key elements of thepatient’s needs and goals. This is key information that shouldbe relayed during the transfer-of-care process.

Communication is considered a domain within several frame-works for nursing education, practice, and research. Accordingto the American Association of Colleges of Nursing (AACN),communication is an essential component of baccalaureate ed-ucation for professional nursing practice, especially as it relates toan interdisciplinary approach to care.3 For the perioperative RN,communication is a required competency that facilitates patientcare within the perioperative environment and during the

transfer of care. In addition, communication and transfer ofcare are major topics of the CNOR� certification examination.4

Understanding effective versus problematic communicationcan aid perioperative nurses in performing successful transfersof care. The following discussion promotes awareness of theissues and desired outcomes involved with health carecommunication.

Effective Health Care CommunicationOptimal communication in the health care environment isdefined as an information-sharing experience in which all teammembers generate input using a variety of methods, includingverbal, nonverbal, and written forms.5,6 This experience in-volves a cyclical process of sending, receiving, and solicitingfeedback, but to be effective, it must be accurate, timely, andmutually understood. The quality and quantity of the collec-tive process of information sharing depends on the exchange ofcommunication occurring across the hierarchical boundaries ofthe organization, between the patient and the surgical team,and vertically and horizontally among all team members.

The nurse’s ability to communicate within an interdisciplinaryteam is a hallmark of the perioperative environment. Teammember relationships are a central factor in the creation of anopen and honest work environment, and all forms ofcommunication are encouraged, including differences ofopinion.7 In health care, communication is categorized as ateamwork-related behavior that helps ensure patient safety,which cannot be overestimated.8 The authors of a literaturereview of team characteristics identified communication asone of the top 10 characteristics of successful surgical teams.9

Problematic Health Care CommunicationThe Joint Commission continues to identify errors incommunication as a root cause of sentinel events.10 Inaddition, The Joint Commission has identified improvinghealth care communication as one of the 2015 NationalPatient Safety Goals.11 The work of nurses is complex, anderrors in health care communication occur when health careteam members are under stress, in high-task situations (eg,critical junctures during patient transfer), and wheninterrupted during an episode of communication, all ofwhich compromise the accuracy and completeness ofinformation transfer. Nurses are well educated to manage anarray of tasks related to decision making, prioritizing, andorganizing, but interruptions can interfere with thiscognitive process.12 In addition, team members are moreprone to errors when they do not have a clear understanding

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of their role; do not feel supported (eg, administratively,interpersonally, professionally), respected, valued, understood,or listened to; and lack adequate training in providinghigh-quality health care information to one another andto the patient.13

Communication also affects patient satisfaction and compli-ance. Poor communication between patients and health careproviders occurs for several reasons, including when patientsare not provided the opportunity or time to tell their story orexplain their history; when they are interrupted, which com-promises diagnostic accuracy; and when they feel they are notbeing listened to. If patients feel that care instructions are toodifficult to follow or they do not understand what they aresupposed to do, this can affect compliance with care in-structions. In addition, poor communication may cause pa-tients to feel that the care instructions go against their personalbeliefs and that health care providers are either ignoring thoseconcerns or are unaware of them.13

USING COMMUNICATION TOOLSDURING CARE TRANSFERSAccording to AORN, the purpose of the “Guideline fortransfer of patient care information” is to provide “guidance toperioperative nurses for safe transfer of patient information tosubsequent health care providers.”14(p583) Perioperative nursesare responsible for patients under their direct supervision andfor providing accurate information when transferring thepatient to another unit or practitioner.

The nurse who transfers care of the patient during the handover is responsible to convey vital patient information to thenurse who receives the patient. Whenever possible, providingpatient information via written and verbal segments should bepart of a standardized communication format delivered in aface-to-face exchange.14 Although anticipating the needs ofteam members is often a sign of experience and criticalthinking skills, health care providers who are successful withtransfer-of-care communication often use tools that arestandardized, tested, and uniformly applied across systems.In response, professional organizations have developed toolssuch as checklists, time outs, and briefings with patientsafety in mind. Errors in health care communication can bereduced through the use of these tools, along withinterdisciplinary team training and continual evaluation ofthe effectiveness of these tools.15

ChecklistsThe World Health Organization’s (WHO) Surgical SafetyChecklist exemplifies effective transfer-of-care communication

(Figure 1). When using this checklist, the nursing teammembers, along with the surgeon and anesthesiaprofessional, have an opportunity to ask questions and voiceany concerns they may have related to the patient.16

Through its Safe Surgery Saves Lives initiatives, the WHOchecklist, along with an implementation manual, has beenmade available to facilities worldwide in an effort to reduceadverse events in surgery.17 The WHO highlights the factthat the checklist is not intended to be comprehensive andencourages users of the checklist to adapt and makemodifications to fit their practice as needed. The intent ofthe WHO implementation manual is to guide practitionerstoward consistency in their use of the surgical safetychecklist.18

AORN offers a comprehensive surgical checklist, included inits Correct Site Surgery Tool Kit,19 which is a valuableresource for perioperative nurses (Figure 2). This color-coded checklist integrates components from the WHO, theUniversal ProtocolTM,20 and the National Patient SafetyGoals.21 A more recent iteration of the WHO checklist hasbeen developed in collaboration with the Safe Surgery 2015campaign and the Harvard School of Public Health andincorporates additional check points, including briefing anddebriefing sections to coincide with before induction ofanesthesia, before skin incision, and before a patient leavesthe room (Figure 3).22 Health care facilities have a variety ofchecklists to choose from in developing evidence-basedtransfer-of-care processes.

There has been an overall increase in the use of surgical checklistbriefings, as evidenced by an increase in publications on the useof these tools.23 In a review of the literature on the effectivenessof a surgical safety checklist, results from four studiesdemonstrated that breakdowns in communication, causingactive errors, could be prevented with the use of a checklist.24

However, the increased use of such tools and the quantity oftools used in practice may not assuage concerns regarding thelink between adverse surgical outcomes and process errors,which continue to occur because of deviations in practice.24

BriefingsThe use of briefing and debriefing tools is designed for tar-geted use in different phases or contexts of patient care, andthe tools often are incorporated within a checklist. Forexample, a Johns Hopkin’s team developed an OR briefingtool designed to encourage teamwork and communication inthe OR during the preoperative period.25 By performing astructured briefing session, the perioperative team can verifythat they are effectively conveying critical information

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(eg, correct patient, correct site). The same team developed anOR debriefing tool that provides a structured format for adebriefing session.26 Its goal is to focus the team’s effort onfinalizing critical processes occurring within the operativephase, including verification of correct counts and specimenlabeling, as well as providing the opportunity to assess thesurgical team’s nontechnical skills and reflect on overall teamperformance.26 The focus of a briefing is for the team toattend to patient information before the surgery, whereas thefocus of the debriefing is to evaluate the actions of the teamduring surgery and before patient transfer to the next phaseof care.

Time OutsThe time out is part of The Joint Commission’s UniversalProtocol for Preventing Wrong Site, Wrong Procedure, andWrong Person SurgeryTM and is a collective, structured pausethat provides an opportunity to verify critical patient infor-mation to prevent never events, such as wrong-site surgery.27

The emphasis of the time out is on the immediate periodbefore an incision or start of an operative or other invasive

procedure. At a minimum, during the time out, teammembers must agree on the patient’s identity, surgical site,and surgical procedure. The intent of the time out is topromote safe practices in the perioperative setting. Use ofthe time out is a crucial safety process that the perioperativenurse is well positioned to initiate.

Interdisciplinary TrainingTo support improved communication, several interventionshave been developed and tested not only to sustain team unityand integration, but also to leverage those dynamics for de-livery of quality patient care. These interventions include teamtraining programs and use of standardized team communica-tion tools and protocols. For example, Crew Resource Man-agement is a training program designed by the aviationindustry to provide team members with cognitive and inter-personal skills that help reduce human error,28 andTeamSTEPPS� is an Agency for Healthcare Research andQuality and Department of Defense national program aimedat improving patient safety through teamwork and improvedcommunication skills.29

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Figure 1. The World Health Organization Surgical Safety Checklist. Reprinted with permission from the WorldHealth Organization, Geneva, Switzerland.

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Testing, Efficacy, and Team PerceptionThe use of communication tools warrants periodic testing oftheir usefulness in practice. A tool’s effectiveness often dependson how the surgical team perceives the efficacy of the tool andon periodic testing of its effectiveness.30 In a study designed toreduce adverse outcomes in surgery through the use of a briefingchecklist, researchers used a questionnaire to evaluate whetherthe use of the checklist correlated with study participants’perceived risk of reduction in wrong-site surgery occurrences.31

Analysis of the responses showed that study participants felt asignificant level of certainty in the correct site location as aresult of the use of an OR briefing tool (P ¼ .001). Thesefindings suggest that although a proliferation of tools havebeen developed, team members’ commitment to thesustainability of the process has a direct effect on whether use

of interventions will positively affect processes related topatient safety and clinical outcomes. Team members mustperceive the intervention as valuable for it to be useful inpractice.31 Team members will be more willing to continueusing a tool if they see a direct correlation between it andpositive patient outcomes while also recognizing that tangibleresults from any intervention require consistency and may taketime to implement before seeing positive results.

STRATEGIES FOR CONVEYINGINFORMATIONEach facility may have specific standardized content for in-clusion in care transfers, which will dictate the required level ofdetail in the communication tools used. Terms such as handoff, hand over, sign over, and shift report may be used

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Figure 2. AORN’s Comprehensive Surgical Checklist. N/A, not applicable; SCIP, Surgical Care ImprovementProject. Reprinted with permission from AORN. Copyright ª 2015, AORN, Inc, 2170 S. Parker Road, Suite 400,Denver, CO 80231. All rights reserved.

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interchangeably to identify standard documentation tools orprocesses used when transferring the care of a patient. Theintent of optimal transfer-of-care communication is to makethe patient transfer as safe and efficacious as possible.

Body language, facial exchanges, and eye contact arecommunication channels available to practitioners during anin-person exchange. Similar to the holistic care of a patient, allforms of communication can contribute to the overall assess-ment of the patient’s condition. Many communication tech-niques may be used to enhance information exchange whenperforming hand overs. Such techniques should provide op-portunities for team members to ask questions and clarify andconfirm information. Examples of these techniques include

� SBAR (situation, background, assessment, recommendation),� I PASS the BATON (introduction, patient, assessment,situation, safety concerns, [the] background, actions, timing,ownership, next),

� the Five Ps (patient, plan, purpose of plan, problem, pre-caution), and

� the Five Ps, second version (patient, precautions, plan ofcare, problems, purpose).32,33

Although these formats are generalizable across care settings,they are not specific to the perioperative environment. Peri-operative practitioners have developed SWITCH, a hand-overtool for use in the perioperative setting. The SWITCHmnemonic stands for

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Figure 3. The Safe Surgery 2015 Checklist template. DOB, date of birth. Used with permission from Safe Surgery2015: South Carolina.

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� Surgical procedure,� Wet (ie, fluids),� Instruments,� Tissue (ie, specimens),� Counts, and� Have you any questions?34

In an article on the effectiveness of the SWITCH tool, the authorsdescribed the use of this tool and, one year after its implementa-tion, distributed a survey to team members to obtain feedbackabout compliance with use of the tool. Results of the surveyindicated that 97%of respondents believed the SWITCHtoolwasimportant to patient safety and that 87% felt it was easy to use.34

The perioperative area can be an intimidating environment.Support for staff who voice their concerns should be a priority;however, in the perioperative setting, such support can be highlyvariable. One simple tool for health care personnel to use whenvoicing a concern is to simply state “I’m concerned that . . .” if amore detailed SBAR approach or other tool for communication isnot possible. The simple voicing of a concern has emerged as a flagin health care settings. Although the step of speaking up andvoicing concerns by any member of the perioperative team isembedded in standardized checklists, members may be reluctantto speak up until a culture change is evident in the work envi-ronment. Consistent use of a checklist that promotes communi-cation can assist in establishing a culture change, leading teammembers to feel confident in raising concerns about the patient.35

Perioperative patients undergo several transfers of care duringthe preoperative, intraoperative, and postoperative phase.Whenever possible, the patient is an active participant in theprocess, providing and validating key pieces of informationregarding his or her care. The electronic health record containscertain patient information and serves as a baseline knowledgedatabase but does not always account for the affective domainof a patient’s health, such as anxiety levels or unrealistic ex-pectations from the patient or family member.36 A patient’shealth status can change quickly; therefore, it is imperativethat practitioners receive the patient’s most current status,particularly during transfers of care.

Several variables factor into a successful transfer-of-care expe-rience, including a standardized policy, effective teamwork,education, benchmark data, and quality checks. As an exem-plar of successful care transfers, a surgical team reported nowrong-site surgery occurrences in 900 operations during a 15-month period at a two-bed OR in a combat zone in Iraqdespite a 100% turnover rate for surgeons every 180 days,with anesthesia professionals rotating through the combatsupport hospital as frequently as every 90 days.37

Addressing Areas of ConcernSafeguarding the patient from adverse events is of utmostimportance when designing communication tools. Areas ofconcern in the perioperative environment can range fromturnover among personnel when shift changes occur tochanges for breaks and meals. Therefore, the mode and typeof communication may vary according to the context, such aspermanent replacement of team members when shifts changeversus break and meal relief. It is within the purview of fa-cility administrators to decide, along with the point-of-carepractitioners, which communication and safety tools shouldbe used within each context of care, with the underlyingcaveat that patient safety is the top priority. Deviating fromestablished procedures to accommodate staff or shift changesmay have negative consequences and cause unnecessary riskto patients. Cutting corners or inventing workarounds (eg,not performing a time out) may be perceived as a short-termsolution in a few instances (eg, in response to pressure to starta procedure on time), but could result in poor practicestandards that build over time. Changing behavior is difficultto achieve in the best of circumstances, and these deviationsfrom acceptable practice could become problematic if stepsare not taken to promote and maintain standardizedcompetent practice.

HAND-OVER COMMUNICATION BYPHASE OF CAREDifferent phases of care will dictate which patient informationshould be conveyed in the perioperative triad process (Figure 4).In the preoperative point-of-care phase, verifying the patient,surgical site, and procedure is essential. Other content toverify during this phase of care may include the following:

� site marking is complete and accurate;� legal patient documents including consents and durablepower of attorney are present;

� NPO status, allergies, vital signs, medications, and pertinentlaboratory and other test results are documented;

� quality measures such as prophylactic antibiotic adminis-tration, beta-blocker therapy, and venous thromboembolismprophylaxis have been instituted or continued;

� pertinent cultural, social, and spiritual needs are addressed;and

� the patient is ready for transfer.14

In the intraoperative phase of care, there are further oppor-tunities to continue the interdisciplinary communication triad.As in all phases of care, standardized communication toolsmay be used, including a time out. A time-out procedurecontinues to be a component of the Universal Protocol and a

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mainstay of The Joint Commission’s 2015 National PatientSafety Goals.21 In a literature review on implementing theUniversal Protocol, findings indicated an array of themessurrounding the state of knowledge on the topic and itslink to the occurrence of wrong-site, wrong-person, andwrong-procedure operations.38 The authors of the literaturereview organized their findings according to gaps, areas ofconcern, and significant trends; they concluded thatimplementation of the Universal Protocol differs from

facility to facility.38 A time out may be used as a stand-alone formal procedure or as part of a larger surgicalchecklist. For example, team members in one facilityimplemented the use of dry erase boards labeled withspecific time-out elements.39 Anecdotally, team membersreported improved communication and access toinformation.39 In a seminal study on the use of a time outwithin the larger context of a surgical safety checklist,results showed a reduction in postoperative complicationsand death rates (from 1.5% to 0.8%; P ¼ .033) in patientsat least 16 years of age undergoing noncardiac surgery.40

The postoperative phase completes the perioperative triadprocess in the transfer of patient care information. An ongoingevaluation and stabilization of the patient occurs in this phase,and it is essential that the perioperative nurse provide acomprehensive report to the receiving nurse in the post-operative setting. Essential patient issues to communicateduring this phase of transfer may include

� surgical procedure performed and presence or absence of anycomplications;

� surgeon and anesthesia care provider orders;

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Figure 4. Communication pathways and tools avail-able to be used during transfer of care. 5Ps, patient,plan, purpose of plan, problem, precaution (secondversion: patient, precautions, plan of care, problems,purpose); I PASS the BATON, introduction, patient,assessment, situation, safety concerns, (the) back-ground, actions, timing, ownership, next; SBAR, situ-ation, background, assessment, recommendation;WHO, World Health Organization.

Eight Checklist Mistakes to AvoidAlong with consistent use and full participation on thepart of team members to support successful use ofchecklists, there are practical steps practitioners can take toavoid common mistakes in checklist implementation.1. Do not remove communication steps when tailoring

checklists to fit your practice.2. Do not make the checklist a catch-all. It is not a risk

management disclaimer, but rather a tool aimed atfeasibility and best practices.

3. Do not wait to engage physicians, and do not un-derestimate the power of one-on-one conversations.

4. Do not skimp on preimplementation education andpreparation.

5. Do not forget to “test drive” the checklist.6. Do not choose an arbitrary launch date; be flexible.7. Do not audit. Coach teams, and never stop looking

for ways to improve team performance.8. Do not worry about those who are against [the

checklist] or who may not yet understand the valueof the checklist.1

Reference1. 8 checklist mistakes to avoid. March 20, 2013. AORN

Periop Insider. https://www.aorn.org/News.aspx?id¼24542.Accessed June 12, 2015.

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� vital signs, hemodynamic status, and information about thesurgical site;

� type of anesthesia;� administered IV fluids; and� family/significant other information.

As in any phase of perioperative care, patient acuity, specificquality measures, identified safety risks, and real-time changesin patient status will factor into which type and the amount ofinformation that needs to be conveyed. Regardless of the toolor phase, the intent is to promote effective communication,agile workflows, teamwork, and optimal care.

CONCLUSIONCommunication is the basis of human interaction. How in-dividuals communicate (ie, behaviors, methods, intent) isimportant and can contribute to miscommunication; in theperioperative care environment, the content that care providerscommunicate is vital as well. Achieving goals for effectivecommunication is contingent on collaboration, negotiation,and relationship building within a highly functioning team ofhealth care providers. To remain competent in practice,perioperative nurses should include communication theoryand models, leadership essentials, and decision-making modelsin their continuing education. Through effective communi-cation, practitioners can gain each other’s trust and respect intheir determination to provide patients with a safe periopera-tive experience. �Editor’s notes: CNOR is a registered trademark of the Compe-tency and Credentialing Institute, Denver, CO. The UniversalProtocol for Preventing Wrong Site, Wrong Procedure, WrongPerson Surgery is a trademark of The Joint Commission, Oak-brook Terrace, IL. TeamSTEPPS is a registered trademark of theUS Department of Defense, Falls Church, VA, and the USDepartment of Health and Human Services, Bethesda, MD.

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23. McDowell DS, McComb SA. Safety checklist briefings: a sys-tematic review of the literature. AORN J. 2014;99(1):125-137.

24. Collins SJ, Newhouse R, Porter J, Talsma A. Effectiveness of thesurgical safety checklist in correcting errors: a literature reviewapplying Reason’s Swiss cheese model. AORN J. 2014;100(1):65-79.

25. Makary MA, Holzmueller CG, Thompson D, et al. Operating roombriefings: working on the same page. Jt Comm J Qual Patient Saf.2006;32(6):351-355.

26. Makary MA, Holzmueller CG, Sexton JB, et al. Operating roomdebriefings. Jt Comm J Qual Patient Saf. 2006;32(7):407-410.

27. Never Events. AHRQ Patient Safety Network. http://psnet.ahrq.gov/primer.aspx?primerID¼3. Accessed May 19, 2015.

28. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD,van Wijk KP. Interventions to improve team effectiveness: a sys-tematic review. Health Policy. 2010;94(4):183-195.

29. TeamSTEPPS: national implementation. Agency for HealthcareResearch and Quality. http://teamstepps.ahrq.gov/. AccessedFebruary 15, 2015.

30. Marsteller JA, Holzmueller CG, Makary M, et al. Developingprocess-support tools for patient safety: finding balance betweenvalidity and feasibility. Jt Comm J Qual Patient Saf. 2008;34(10):604-607.

31. Makary MA, Mukherjee A, Sexton JB, et al. Operating roombriefings and wrong site surgery. J Am Coll Surg. 2007;204(2):236-243.

32. Patient Hand Off Communication Tool Kit. AORN. http://www.aorn.org/toolkits/patienthandoff/. Accessed June 12, 2015.

33. Sandlin D. Improving patient safety by implementing a standard-ized and consistent approach to hand-off communications.J Perianesth Nurs. 2007;22(4):289-292.

34. Johnson F, Logsdon P, Fournier K, Fisher S. SWITCH for safety:perioperative hand-off tools. AORN J. 2013;98(5):494-507.

35. Huang L, Kim R, Berry W. Creating a culture of safety by usingchecklists. AORN J. 2013;97(3):365-368.

36. Crosson JA. Keeping patients safe: the importance of collabora-tion. AORN J. 2015;101(2):279-281.

37. Harrington JW. Surgical time-outs in a combat zone. AORN J.2009;89(3):535-537.

38. Conrardy JA, Brenek B, Myers S. Determining the state ofknowledge for implementing the Universal Protocol recommen-dations: an integrative review of the literature. AORN J. 2010;92(2):194-207.

39. Edel EM. Increasing patient safety and surgical team communi-cation by using a count/time-out board. AORN J. 2010;92(4):420-424.

40. Haynes A, Weiser T, Berry WR, et al. A surgical safety checklist toreduce morbidity and mortality in a global population. N Engl JMed. 2009;360(5):491-499.

Robin Chard, PhD, RN, CNOR, is an associate pro-fessor in the Nova Southeastern University College ofNursing, Nova Southeastern University, Fort Lauderdale,FL. Dr Chard has no declared affiliation that could beperceived as posing a potential conflict of interest in thepublication of this article.

Martin A. Makary, MD, MPH, is the surgical director,Johns Hopkins Multidisciplinary Pancreas Clinic and aprofessor of surgery and professor of Health Policy &Management at the Johns Hopkins Bloomberg School ofPublic Health, Baltimore, MD. Dr Makary has no declaredaffiliation that could be perceived as posing a potentialconflict of interest in the publication of this article.

October 2015, Vol. 102, No. 4 Transfer-of-Care Communication

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EXAMINATION

Continuing Education:Transfer-of-Care Communication:Nursing Best Practices 2.1 www.aorn.org/CE

PURPOSE/GOALTo provide the learner with knowledge specific to transfer-of-care communication.

OBJECTIVES1. Explain why communication tools are needed in the perioperative setting.2. Identify barriers to communication.3. Describe common communication tools in use in the OR.

The Examination and Learner Evaluation are printed here for your convenience. To receivecontinuing education credit, you must complete the online Examination and Learner Evaluationat http://www.aorn.org/CE.

QUESTIONS1. Safe systems, protocols, and triggers are increasingly

recognized as contributing toa. better reimbursement.b. good patient outcomes.c. improved team enjoyment.d. promotion.

2. The use of communication tools within the context of astrong culture of teamwork has been observed to have agreater proportional effect on patient outcomes thancertain new medications and innovative procedures.a. true b. false

3. Some factors that contribute to communication errors inhealth care that can compromise the accuracy andcompleteness of information transfer include1. complex tasks.2. stress.3. a noisy environment.4. physical impairments.5. interruptions.

a. 4 and 5 b. 1, 2, and 5c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

4. Team members are more prone to errors if they1. do not have a clear understanding of their role.2. are having a difficult day.3. do not feel supported, respected, valued, or

understood.4. are assigned to procedures they do not like doing.5. lack adequate training in providing high-quality

health care information to one another and to thepatient.

6. lack language skills.a. 1, 3, and 5 b. 2, 4, and 6c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

5. Factors that contribute to poor communication betweenpatients and health care providers include when patients1. are interrupted.2. do not have the time or opportunity to explain their

history.3. feel that care instructions are too difficult to follow.4. feel they are not being listened to.5. feel that health care providers are ignoring their

concerns or are unaware of them.a. 1 and 2 b. 3, 4, and 5c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5

340 j AORN Journal www.aornjournal.org

6. Basic interpersonal tools for communication includeproviding patient information via written and verbalsegments and should be part of a standardized commu-nication format delivered in a face-to-face exchange.a. true b. false

7. Professional organizations have developed checklists, timeouts, and briefingsa. to improve reimbursement.b. to reduce OR time.c. to improve team enjoyment.d. to improve patient safety.

8. When using The World Health Organization’s SurgicalSafety Checklist, the nursing team, along with the sur-geon and anesthesia professional, have1. an opportunity to ask questions.2. an opportunity to eliminate parts of the checklist.3. an opportunity to voice any concerns they may have

related to the patient.4. an option to not participate.

a. 1 and 2 b. 2 and 4c. 1 and 3 d. 1, 2, 3, and 4

9. By performing a structured briefing session, the periop-erative team can verify that they area. improving reimbursement.b. reducing OR time.c. improving turnover time.d. effectively conveying critical information.

10. Some communication techniques that may be used toenhance information exchange when performing handovers include1. SNITCH (surgery, not applicable, intraoperative

care, concerns, hand over).2. SBAR (situation, background, assessment, recommendation).3. I PASS the BATON (introduction, patient, assess-

ment, situation, safety concerns, [the] background,actions, timing, ownership, next).

4. Five Ps (patient, plan, purpose of plan, problem,precaution).

5. Five Ps, second version (patient, precautions, plan ofcare, problems, purpose).

6. Four Ss (surgery, surgeon, surprises, successes).a. 1, 3, and 5 b. 2, 4, and 6c. 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6

October 2015, Vol. 102, No. 4 Transfer-of-Care Communication

www.aornjournal.org AORN Journal j 341

LEARNER EVALUATION

Continuing Education:Transfer-of-Care Communication:Nursing Best Practices 2.1 www.aorn.org/CE

This evaluation is used to determine the extent towhich this continuing education program metyour learning needs. The evaluation is printed

here for your convenience. To receive continuing educationcredit, you must complete the online Examination andLearner Evaluation at http://www.aorn.org/CE. Rate the itemsas described below.

PURPOSE/GOALTo provide the learner with knowledge specific to transfer-of-care communication.

OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Explain why communication tools are needed in the

perioperative setting.Low 1. 2. 3. 4. 5. High

2. Identify barriers to communication.Low 1. 2. 3. 4. 5. High

3. Describe common communication tools in use in theOR.Low 1. 2. 3. 4. 5. High

CONTENT4. To what extent did this article increase your knowledge of

the subject matter?Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this articlein your work setting?1. Yes 2. No

7. Will you change your practice as a result of reading thisarticle? (If yes, answer question #7A. If no, answerquestion #7B.)

7A. How will you change your practice? (Select all thatapply)1. I will provide education to my team regarding why

change is needed.2. I will work with management to change/implement

a policy and procedure.3. I will plan an informational meeting with physicians

to seek their input and acceptance of the need forchange.

4. I will implement change and evaluate the effect ofthe change at regular intervals until the change isincorporated as best practice.

5. Other: __________________________________

7B. If you will not change your practice as a result ofreading this article, why? (Select all that apply)1. The content of the article is not relevant to my

practice.2. I do not have enough time to teach others about the

purpose of the needed change.3. I do not have management support to make a

change.4. Other: __________________________________

8. Our accrediting body requires that we verify the timeyou needed to complete the 2.1 continuing educationcontact hour (126-minute) program: _____________

342 j AORN Journal www.aornjournal.org