Nurse Handovers and Patient Safety

The assignment delves into the relationship between ineffective nurse handovers and patient adverse events stemming from medical errors. It analyzes various handover protocols like SBAR, SHARQ, I-PASS, and resident handoff bundles, evaluating their impact on reducing information omissions and medical error rates. The document also highlights a study identifying latent factors contributing to medication administration errors, emphasizing the importance of organizational interventions for enhancing patient safety. A summary table synthesizes findings from relevant studies.

Running head: THE NURSE HANDOVER
THE NURSE HANDOVER
Name of the Student
Name of the University
Author Notes

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Abstract
Background: Handovers are critical in maintaining a proper communication and transfer of
patient information during shift changes of nursing professionals. According to the NHS, nurse
handovers are defined as the “nursing change of shift report or handover is a communication that
occurs between two shifts of nurses whereby the specific purpose is to communicate information
about patients under the care of nurses” (Wales.nhs.uk 2018). Miscommunication and omissions
of patient information can give rise to serious consequences in the form of medical errors, which
in turn constitutes most of the preventable injuries that occur in various hospital and nursing
homes. There are several studies that try to understand the various factors responsible for
improper handover preparation and also examines various interventions that can help in
preventing such handover preparation.
Aim: The purpose of this dissertation is to determine the various factors responsible for
ineffective handover preparation and how these can be prevented by the implementation of
various interventions. To achieve this aim, a literature review has been carried out to explore the
various studies dealing with this particular topic.
Method: A literature review was carried out using the PubMed and Google Scholar databases
and 5 studies have been selected for this dissertation. Out of the 5, 3 are quantitative, one is a
qualitative and the other is a quasi-experimental study.
Results: The results from the literature review revealed that lack of proper education and
training of the nurses with respect to handover preparation led to miscommunication and
omission of patient information, which in turn gave rise to medical errors. The results also reveal

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the study of a large number of interventions that have been found to improve the ability of the
nurses to prepare effective handovers.
Conclusion: Thus, the evidences suggest that effective communication during patient handovers
results from proper training, education of the nurses and by standardization of a handover
protocol. Thus, by the establishment of the above interventions can prevent adverse patient
outcomes.

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Table of Contents
Introduction......................................................................................................................................4
Background and rationale for the study...........................................................................................5
Research question............................................................................................................................7
Mode of literature search.................................................................................................................8
Literature review..............................................................................................................................9
Critic of literature..........................................................................................................................14
Introduction................................................................................................................................14
Critique......................................................................................................................................15
Conclusion.................................................................................................................................17
Discussion......................................................................................................................................18
Implications on the nursing practice..............................................................................................19
Reference List................................................................................................................................20
Appendix 1.....................................................................................................................................24
Appendix 2.....................................................................................................................................25
Appendix 3.....................................................................................................................................25

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Introduction
This report forms the basis of the dissertation proposal, which is aimed to determine the
importance of nurse handovers. The dissertation will consist of an abstract, which will have a
brief outline of the background of the study, the aim, methodology, results and conclusion. A
thorough literature review will form a part of the dissertation as it will help to solve the research
question that will be addressed in this work. Finally, a discussion will be provided summarizing
the main findings of the literature review and a conclusion will be generated about the
importance of the topic. The report will also address the implications of the research topic with
respect to safe nursing practices.
A research proposal sets out the background for addressing a particular problem. It
consists of a series of steps that ultimately results in solving of the research question that was
laid out at the initial stages of the dissertation (Modesto 2013). A good quality dissertation
consists of concise, clear and interesting information with respect to the topic. It is meant to be
highly organized, connected in a seamless manner, asks and addresses a question and displays a
deep understanding of the subject (Abdulai and Owusu-Ansah 2014). Nursing research impacts
nursing practices in a tremendous manner as it introduces new findings and information, which
the nurses can utilize to provide safe and effective care to patients (Atkinson 2013). The primary
goal of all nursing professionals is to advocate patient safety and provide effective care to the
patients based on evidence-based practices. Evidence based practices are based on research and
nursing professionals engage themselves in research in order to provide effective care to patients
that are backed by clinical evidence (Black et al. 2015). A handover is an essential part of
nursing practices as it forms the basis on which the nurses provide safe and effective care to

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patients. A nurse handover consists of the medical history of patients, current medical status of
the patient and the future treatments that need to be given (Ewing 2015; Bruton et al. 2016).
Thus, keeping in mind the importance of nurse handovers, the topic of the dissertation is
nurse handovers.
Background and rationale for the study
Nurse handovers with respect to shift changes is an important concept of nursing care.
Communication is a vital part of nursing care and is highly essential during transfer of patient
information from one healthcare professional to another (Eggins and Slade 2015). The handover
also called the shift change is associated with transferring of patient care and can be defined as a
“report or ritual given when the nursing professional transfers the responsibility for the patients
and what has been done in his or her shift to another that is arriving” (Guevara Lozano, Maries
and Patricia 2015). According to the NHS, poor communication during handovers can give rise
to major preventable harms to the patient (Who.int 2018). Although a good handover depends on
a good communication, the various stages where a communication gap can give rise to errors in
patient care are shift changes, transfer of care between different staff groups, transfer of care
between departments and transfer of care between different care settings (Flemming and Hübner
2013). Such lack of proper communication between healthcare professionals or between different
departments of a healthcare organization result in adverse and unfavourable patient outcomes.
These include poor care of patients, risks of patient safety, poor use of staff resources, patient
death, complaints, litigations, among others (Eggins and Slade 2015).
In order to avoid such adverse events that can give rise to tremendous loss to both
patients as well as the healthcare organization, the NHS recommends the use of two important

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techniques. These are standardization and streamlining. Standardization enables the participants
involved in the care of the patient to follow the same procedure and also communicate the same
information. This in turn results in positive impact on the quality of care provided to the patients
and also increases the productivity of the healthcare organization. Streamlining is defined as the
process by which unnecessary steps in the handover process is identified and removed. This in
turn results in simplification of the transfer of patient care, reducing risks, improving quality and
reducing the release time of patients (England.nhs.uk 2015).
The characteristics of shift changes or handovers are regularity, duration, frequency,
location, types of information and participants (Guevara Lozano, Maries and Patricia 2015).
Handovers are considered to be a regular event that takes place during morning, afternoon and
night. However, the nursing professionals find it highly challenging to stay within the stipulated
time, which is usually 15 to 45 minutes depending on the number and severity of medical
condition of the patient (van den Oetelaar et al. 2016). The handover or the shift report contains
information of the patient such as physical, spiritual as well as psychosocial aspects in addition
to information regarding medical history, diagnoses, treatment plans, prescribed medications,
among others. The handover contains sufficient information that can be used to meet the short
and long-term goals with respect to the care of the patient (Tan 2015).
Some of the barriers that can give rise to ineffective transfer of handoff during shift
changes between the nursing professionals are communication barriers, standardization problems
regarding handovers, problems associated with technical difficulties, difficulties faced due to
patient complexities, large number of patients, lack of education and training of the nursing
professional as well as other human factors (Pun et al. 2015). Various studies have reported the
importance of handovers during transfer of patient duties between nursing professionals.

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However, ineffective handovers or shift reports can give rise to adverse events with respect to
patient health and can even result in death. This is usually associated with the occurrence of
medication errors, delaying of treatments, increase unfavourable patient outcomes, reduce patient
satisfaction, prolongs the hospital stay for the patients, brings about economic loss for both
patients and healthcare organizations and ultimately can also result in sentinel events like patient
deaths (Who.int 2018). According to the Joint Commission International, poor transfer of
information during handovers is considered to be the main risk factor associated with 65% of
sentinel events, while it acts as a contextual risk factor associated with 90% of sentinel events
(Duhan, Sembian and Kumari 2016).
Thus, this rationale forms the basis for the dissertation, which is to determine the
effectiveness of nurse handovers for safe transfer of information in order to ensure patient safety.
The aim of the study is to determine the effectiveness of the nurse handovers in providing safe
and effective care to patients.
Research question
The development of a research question is an important first step in addressing the issues
or challenges associated with a particular topic. Interest garnered in a particular topic helps in the
onset of the research process, while familiarity associated with the research topic helps to define
the research question. Research of existing literature helps to determine the various research gaps
associated with the study and the research question arises out of this knowledge gap and
subsequent studies help to address the knowledge gaps (Socscidiss.bham.ac.uk 2018). The
formulation of the research question is based on carrying out a literature search or in-depth
interviews or focus group meetings with patients or experts of the chosen field. It is essential to

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determine the boundary between the current knowledge and the knowledge gaps. Determination
of this boundary helps in the formulation of an appropriate research question, which in turn
paves the way for further research in order to provide new inputs that helps in bridging the
knowledge gaps. There are 4 stages in developing a research question, which are broad topic,
narrow topic, focused topic and the research question (Ggu.libguides.com 2018) (Appendix 1).
These 4 stages were utilized for generating the research topic which is “Does ineffective
nurse handovers give rise to patient adverse events due to medical errors?”
The PICO system provides a framework that helps to refine the research question. The
PICO helps to consider the inclusion and exclusion criteria for the research. The PICO table
defines the inclusion and exclusion criteria, outlines the various interventions and the outcomes
that will be generated after the application of the interventions and also helps to provide the basis
for a thorough literature search on the topic. A PICO table represents the patients or the
problems, interventions, comparisons and the outcomes (O’Brien and DeSisto 2013) (Appendix
2).
Mode of literature search
The search engines used were PubMed and Google scholar. The keywords used for the
search were interventions, effective nursing handovers and medical errors. Sing these keywords
in PubMed generated only one research article, while in Google Scholar, a number of studies
were obtained. The inclusion criteria for the dissertation was use of research articles that were
published between the years 2012 to 2018. Moreover, only primary research articles were used.
The exclusion criteria were research that were published before 2012 will not be used in the
research proposal. Moreover, systematic reviews and studies that did out address the research

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question were excluded from the study. Based on the search, 5 research articles were used to
carry out the literature review.
Literature review
The literature review was carried out based on the information obtained from the 5
research articles (Appendix 3). The first article that is reviewed is that of Younan and Fralic,
(2013), which is titled, “Using best fit interventions to improve the nursing intershift handoff
process at a medical center in Lebanon”. The background of the study that formed the basis of
the research was the lack of communication between outgoing and incoming nurses in the Labib
Medical centre in Saida Lebanon that gave rise to reported incidents with respect to patient
safety. The incidents that were reported were medical or medication errors, wrong treatment,
delayed treatments, near miss events and duplication of diagnostic tests. These incidents were
found to be due to omission of patient informations from the handovers during shifts. The study
helped to identify the barriers that prevented the transfer of patient information in an effective
manner. These barriers that were identified in the study were absence of standardization in the
intershift communication tools, lack of proper training among the registered nurses with respect
to effective handoff communication between shifts and presence of interruptions between the
transfer of shift reports. Based on literature search, the author determined the best-fit strategies
that can be utilized to address the issues identified. The 3 interventions that were identified were
introduction of a standardized intershift handoff tool, education and training in order to improve
the competency levels of the registered nurses in order to carry out effective communication
during handoffs and decreasing the interruptions associated with various steps like physician or
nursing rounds, patient admissions and transfers. The standardized intershift handoff tools that
were utilized were SBAR and SHARQ. The SBAR also called Situation, Background,

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Assessment and Recommendation were circulated to the registered nurses of the cardiac unit,
while the SHARQ also called the Situation, History, Assessment, Recommendation and
Questions were circulated to the registered nurses of the surgical and medical units.
Improvements of the competency levels of the nurses were carried out by training sessions, while
interruptions during handovers were decreased by advising the physicians to not to take rounds
during shift cages and by informing the patients during shift changes. Statistical analysis was
carried out to determine the effectiveness or significance of the interventions. With the
applications of these interventions, the mean number of omissions with respect to patient
information in handoffs were reduced from 4.96 to 2.29. Moreover, the mean number of the
interruptions also decreased during the shift changes, which were found to be decreased from
2.17 to 1.26. The research ivolved comparison of the data pre and post intervention, which
indicated a significant decrease in patient information omission, thereby resulting in decrease in
medical errors following the application of the interventions.
The second article that is used in the literature review is that of Starmer et al. (2014),
which was titled “Changes in medical errors after implementation of a handoff program”. The
background of the study was that miscommunication gives rise to medical errors during transfer
of patient information. Some of the preventable patient adverse events that occur as a result of
ineffective handovers are injuries caused due to medical errors. Failure to communicate the
information regarding patient treatments during handoffs give rise to adverse events also called
the sentinel events. A system-based intervention study was incorporated in the training programs
of the nurses. Data were collected 6 months after the interventions were applied. The data that
were collected were based on medical errors, the quality of the handoffs among others. The
residents of the healthcare units received training with respect to proper handoff practices and

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were advised to use the I-PASS handoff process. The I-PASS handoff bundle tool that were
utilized in this study had seven components. The seven components of the tool were a I-PASS
mnemonic, a 2-hour workshop, a one-hour simulation and role-playing session, a complete based
module, a development program for the faculty, direct observation tools that can be utilized by
the faculty to provide feedbacks, process change and culture change campaigns. Medical error
rates were determined through the use of active surveillance and quality of the handoffs were
determined by evaluating the contents of the handoffs and various audio recordings. The
workflow of the residents was determined by the time motion observation techniques. The
primary outcomes consisted of medical errors and adverse events. Results obtained after the
interventions revealed that of the 10,740 admissions of patients to the healthcare unit, the
medical error rate was significantly decreased from 24.5 to 18.8 per 100 patient admissions.
Thus, the error was reduced by 23% post-intervention as compared to the pre-intervention
period. Moreover, the rate of the adverse events that were preventable also decreased from 4.7 to
3.3 per 100 patient admissions. This decrease was found to be 30%. However, the rate of the
adverse events that were non-preventable did not change significantly. The quality of the
handoffs with respect to inclusion of patient information was also found to be increased post-
intervention. All these in turn helped to reduce the medical errors thereby preventing the
occurrence of adverse events.
The third article that is used for the literature review is a qualitative research based on
interviews conducted with nurses and hospital managers. The study was carried out by Lawton et
al. (2012), and has been appropriately titled “Identifying the latent failures underpinning
medication administration errors: an exploratory study”. The aim of the study was to determine
the latent failures associated with medication errors. Inherent weaknesses of healthcare

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organizations are termed as latent failures that can give rise to failures as a result of their
manifestations in the local working environments. These latent failures are based on decisions
regarding the planning made by seniors, design of the buildings, inappropriate staffing and lack
of proper procurement of equipments. The study design was a qualitative cross-sectional
approach. The methodology of the study was interviews that were conducted among 12 nurses
and 8 managers of a hospital ward in the United Kingdom. Consent was obtained from the nurses
and managers before conducting the interview. Ethical approvals were also obtained from the
ethics committee. However, no literature review was carried out before conducting the
interviews. The subjects of the interviews were organized into themes and the themes were
subjected to a thematic content analysis. The reliability of the themes obtained from the
interviews were tested by sing the 2 step inter rater comparison. The study helped to identify 10
themes or latent failures that gave rise to medication errors. These were local working
environment, ward climate, team communication, workload, human resource, bed management,
written policies, training, routine procedures, leadership and supervision. The importance of the
study lies in the fact that the results obtained can act as the foundation for the provision of patient
safety interventions at the organization level, which involves education and training and
designing of error management tools as well as event reporting systems in the hospital wards.
Another work by Starmer et al. (2013) titled “Rates of medical errors and preventable
adverse events among hospitalized children following implementation of a resident handoff
bundle” also helped to prevent medical errors and occurrence of adverse events. The background
of the study was handoff miscommunications that give rise to adverse events resulting from
medical errors. The intervention study was carried out by including 1255 patient admissions
equally divided between pre and post interventions. The intervention study also included 84

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resident doctors who were also equally divided among the pre and post interventions. The
intervention named the resident handoff bundle involved proper handoffs training and
standardized communication techniques. Moreover, it also included a verbal mnemonic, and a
proper handoff structure for the team. Statistical analysis revealed that the medical errors
decreased from 33.8 to 18.3 per 100 patient admissions. The adverse events that are preventable
also was decreased from 3.3 to 1.5 per 100 patient admissions. Additionally, other changes that
were observed were reduced rates of patient information omissions, increase in the time spent by
the physicians at the patient bedside and provision of verbal handoffs at quiet locations to
prevent misinterpretation of patient information.
The last article is a pre and post intervention quasi experimental study that was carried
out by Malekzadeh et al. (2013), which is titled “A standardized shift handover protocol:
improving nurses safe practice in intensive care units”. According to this study, handover errors
generally result from lack of communication of inter-shift patient information.
Miscommunication or lack of proper communication hampers the quality and continuity of care
provided to critically ill patients. Although development of a standard handover protocol is
paramount, a standard handover protocol is lacking in various healthcare settings. Patients in
intensive care units being high vulnerable depend on the nurses for their care and treatment and
in the process, are highly vulnerable to medical errors that can endanger their lives. The study
determined the effects of a standardized handover protocol designed by them based on the JCI
standards on the ability of the nurses to provide safe and effective treatment and care to the
patients. Nurses were recruited and subjected to theoretical and practical education classes and
training. This was carried out in order to teach the nurses about the newly designed handover
protocol. The data collection was carried out based on shift handover evaluation checklist and

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the nurses safe practice evaluation checklist. The validity and reliability of these checklists were
determined by the content validity index or CVI and the inter-rater reliability method. They
carried out their data analysis using specific statistical software like the SPSS 11.5 software as
well as the paired sample t test and the McNemar test. The nurses ability to utilize the safe
practice checklist were determined pre and post intervention. The mean score of the evaluation
checklist increased from 11.6 to 17.0 post intervention. Thus, the introduction of this protocol
helped to improve the nursing practices, thereby reducing medical errors in the intensive care
units.
Critic of literature
Introduction
This aim of this section is to carry out the critique of 5 articles that have been reviewed in
the above literature review section. The articles are based on the importance of handoffs in
nursing practices and the various interventions that have been used to overcome the
shortcomings and limitations to hand off practices. Critiquing a literature is a mechanism that
helps to obtain feedback that can be utilized to bring about improvements. Critiquing of research
studies is highly essential in the nursing world as it helps the nurses to understand the advantages
and also the limitations associated with the evidences and in turn utilize and implement only
those research works which would be beneficial to the patients in the long run. This section
involves the critique of 5 articles that deal with the shortcomings of the handover process and the
associated medical errors associated with it thereby giving rise to adverse patient outcomes in the
form of admissions to intensive care units, long hospital stays, increased rates of morbidity and
mortality, among others. Nursing handovers play an important role in communicating essential

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informations regarding the patient treatment so that during nursing intershift changes, the
informations are communicated efficiently to the next nursing professional. Communication
failures are the leading cause of various sentinel events that occur in the healthcare
organizations.
Critique
The research articles are mainly qualitative and quantitative research and one of them is a
quasi experimental study. The abstracts of each of the articles gives a clear description of the
contents of the articles. Moreover, the abstract also provides a background information that helps
to give the readers an understanding of the current situation and problems associated with
nursing handovers and the various adverse events associated with it. The authors of the articles
are all experts in the field of medical profession, either doctors or professors in nursing institutes.
Thus, it is expected that the studies reported in the articles are highly relevant to the current
situation. The title of most of the articles gives a clear information about the interventions
studied and the context of using such interventions. Out of the 5 articles, only the article by
Younana and Fralic, (2013) had a definitive research question that put forth to the readers the
problem being addressed. The studies also carried out an effective literature review that put forth
to the readers the background of the handover problem faced by nursing professionals. A
theoretical framework was followed in the case of Lawton et al. (2012). The methods that are
utilized in the study were clearly depicted however, proper descriptions on why such
methodologies were chosen was not given. All the studies except for Starmer et al. (2013) and
(2014) did not undertake in ethical considerations prior to the research. Ethical norms play an
important role in research. Ethical norms promote the research aims, knowledge, prohibit
falsification of data and misinterpretation of data in order to promote truth and subsequent

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minimization of errors (Resnik 2015). Sample sizes were clearly identified in case of all the
studies. Out of the 5 articles, 3 of the articles carried out random sampling techniques, which is
an effective means of testing interventions as it gives rise to elimination of sampling bias.
However, another study by Lawton et al. (2012) carries out a cross-sectional qualitative study
design that involved the use of semi-structured interviews. However, apart from semi-structured
interviews the use of focus groups could have given a much better understanding about the
various organizational factors that give rise to poor handoffs. Focus groups are advantageous
because of the fact that it helps to obtain the opinions, perceptions and feelings of individuals
with respect to a particular topic of concern (Alshenqeeti 2014). As the study dealt on the
perceptions of the nurses with respect to the organizational factors, a focus group could have
been a far better alternative as compared to interviews. However, another study used a quasi
experimental approach, however such studies lack randomization and lack validity with less
definitive conclusions (Kontopantelis et al. 2015). The data collection strategies have been
identified in case of all the studies and proper statistical tests were done for analysis of the data.
The problems that have been addressed in these articles with respect to nursing handovers are
omissions of patient informations, medical errors, various organizational factors that give rise to
improper communication and poor handover preparations, lack of education and training related
to effective handover preparations, lack of a standardized handover protocol, among others. The
studies were carried out using randomized clinical trials as well as literature search methods and
the significance of most of the results were statistically analyzed. The various interventions that
have been studied in these research articles are SBAR and SHARQ techniques, I-PASS handoff
bundle, resident handoff bundle, a standardized handover protocol, among others. One of the
studies also helped to determine the various organizational factors that are responsible for poor

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handover preparation. However, the appropriateness of such organizational factors are needed to
be determined by experimental approaches. However, the effectiveness of the other interventions
had been determined and the results revealed that there was a significant decrease in omissions
of patient informations, decrease in medical errors, improved handover preparations, among
others. However, the qualitative studies that have been carried out needs to be backed by
quantitative research. Moreover, the limitations of these studies are that they utilized only a
limited number of participants, that cannot provide a real depiction of the effectiveness of the
interventions in the real situations. Other limitations of the studies are that the generalizability
associated with the studies. Moreover, the observational design of the studies prevent the
determination of casualties associated with the problems. Questions also arise on the successive
implementation and sustainability of these interventions. Although Younan and Fralic (2013) as
well as Starmer et al. (2014) described about the sustainability of the research, however, the
others did not provide any such information. Each study has depicted the importance and the
relevance of their research. Moreover, in the referencing part, some of the articles have used
systematic review articles. Reviews are not studies but rather a description and summary of
studies that are carried out. It does not involve primary research and as such their use is
questionable in order to validate important discussions. Further studies are required to validate
these interventions. Except for the studies of Starmer et al. (2013) and (2014), all the others have
provided recommendations on carrying out improvements in the field of nursing handovers.
Conclusion
Thus, it can be concluded that all the articles deals with the important topic of handover
preparation and standardization and the adverse events associated with it, but there are various
limitations with respect to methodology or study design and referencing. Moreover, questions

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also arise on the implementations and sustainability of these interventions which needs further
investigations.
Discussion
Patient handovers play an important role in ensuring safe and effective care to patients
(Eggins and Slade 2015; Laugaland, Aase and Barach 2013). However, even though such
standardized handovers are highly required in the healthcare organizations like nursing homes
and hospitals, there is still a lack of such effective handovers that mediate safe communication
among the healthcare professionals. Miscommunication, lack of proper education and training
with regards to effective handover practices results in adverse events that can even result in the
death of the patient. The causes of the adverse events are miscommunication related medical
errors (Manias et al. 2015). Such preventable adverse events are the root cause of patient
admissions in intensive care units, delay in patient discharge as well as gives rise to financial
burden on both the patients as well as the healthcare organization (van Galen et al. 2016). Lack
of proper handover training and education results in omissions of patient information, which in
turn gives rise to undesired sentinel events (Who.int 2018). The studies that are described in the
literature review addresses the research question and provide various intervention strategies that
are shown to have significant impact on the handover process during shift changes. Out of the 5
studies, 3 of the studies were based on random selection of samples. The articles reviewed
carried out both qualitative and quantitative research and the validity or significance of the
results for some of the studies were determined by statistical tests. However, the limitations of
the studies are that the determination of the organizational factors that give rise to adverse events
due to poor handoff preparation were perceived by the nurses or the physicians themselves.
Thus, the validity of these studies is to be determined in a broad scale. Moreover, the

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interventions that have been described were carried out in a particular healthcare organization.
However, the effectiveness of these interventions are to be determined in the global perspectives.
Thus, the literature review provides a backdrop for measuring the factors that give rise to
ineffective handoffs and also will pave the way for determining whether the factors are inter-
related and also the ability of the factors to cause adverse events will be determined
experimentally, which in turn can help to determine other interventions that target these
organizational factors.
Implications on the nursing practice
An effective and highly organized handover helps in continuity of care post transition of
patients from critical care (van Sluisveld et al. 2015). The lack of effective handover protocols
prevents the provision of safe and effective nursing practices with the aim to provide favourable
patient outcomes and prevent medication errors (Elden and Ismail 2016). Determination of the
various factors particularly organizational factors and their effect on effective handover
preparation are lacking. Thus, if the research study achieves in determining the factors that give
rise to ineffective handover preparation using quantitative randomized clinical trials, then this
study will pave the way for determining new factors as well as new intervention strategies that
can target these organizational factors. Thus, this study will contribute significantly to nursing
practices by identifying the effects and relations of the organizational factors on handover
preparation, which were not known previously.

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Appendix 1
Four stages of research question
Broad topic Narrow topic Focused topic Research topic
Nurse handovers Nurse handover and
patient adverse events
Nurse handovers, patient
adverse events and
medical errors
Does ineffective
nurse handovers
give rise to patient
adverse events due
to medical errors
Appendix 2
PICO Table

25THE NURSE HANDOVER
Patient/Problems Intervention Comparison Outcome
Lack of
communication,
patient information
omission, patient
safety
SBAR and SHARQ Pre and post intervention Reductions in
patient information
omissions
Miscommunication
, patient safety
I-PASS handoff
bundle
Pre and post intervention Reduced medical
error rates
Organizational
factors, medical
errors, patient
information errors
Determination of
latent factors
Development of
interventions
targeting
organizational
factors
Handoff
miscommunication
, medical errors
Resident handoff
bundle
Pre and post intervention Reduced medical
error rates
Adverse events
with respect to
patients in
intensive care units
Standardized
handover protocol
Pre and post intervention Reduced medical
error rates
Appendix 3
Literature review summary table
Author Aim Design Method Results
Younan
and Fralic
(2013)
Using best fit
interventions to improve
the nursing intershift
SBAR and
SHARQ
Quantitative Comparison of the
data pre and post
intervention,

26THE NURSE HANDOVER
handoff process at a
medical center in
Lebanon
indicated a
significant decrease
in patient
information
omission, thereby
resulting in decrease
in medical errors
Starmer et
al. (2014)
Changes in medical errors
after implementation of a
handoff program
I-PASS
handoff
bundle
Quantitative The medical error
rate was
significantly
decreased from 24.5
to 18.8 per 100
patient admissions.
The rate of the
adverse events that
were preventable
also decreased from
4.7 to 3.3 per 100
patient admissions.
The quality of the
handoffs with
respect to inclusion
of patient

27THE NURSE HANDOVER
information was also
found to be
increased post-
intervention. All
these in turn helped
to reduce the
medical errors
thereby preventing
the occurrence of
adverse events.
Lawton et
al. (2012)
Identifying the latent
failures underpinning
medication administration
errors: an exploratory
study
Determinatio
n of latent
factors
through
interviews
Qualitative The results obtained
can act as the
foundation for the
provision of patient
safety interventions
at the organization
level, which involves
education and
training and
designing of error
management tools as
well as event