Publication Date


Degree Awarded Date

December 22, 2022



Background and Review of Literature: Communication errors are a leading cause of preventable medical errors and inadequate handoffs have been linked to sentinel events. Research has shown that standardizing handoff processes can reduce errors, improving patient safety, and resulting in other positive outcomes including increased staff satisfaction, without impacting handoff duration.

Purpose: The purpose of this project was to determine how the implementation of a standardized handoff tool would impact perceptions of handoff communications, retention of important patient information relayed during handoffs, staff satisfaction, and handoff duration.

Implementation Plan and Methods: Information regarding use of the tool was sent to Certified Registered Nurse Anesthetists via e-mail and was also on flyers posted in anesthesia workspaces. Further education was provided prior to intraoperative handoff assessments if necessary. A pre-implementation survey was administered to assess perceptions of current handoff processes. A prospective, observational assessment was then performed to assess the relaying and retention of patient information between Certified Registered Nurse Anesthetists both prior to and after implementation of a standardized handoff tool. These handoffs were timed to measure duration. A post-handoff assessment was administered to further assess information retention. Finally, a post-intervention survey was administered for comparison to the pre-intervention survey. Results were analyzed to determine next steps.

Implications/Conclusion: Significant adverse events including death may occur as a result of inadequate intraoperative handoffs. Anesthesia providers at Barnes-Jewish Hospital have the potential to implement a simple, low-cost, evidence-based intervention that can help curb the occurrence of these events, thus avoiding patient harm while also reaping the benefits of increased provider satisfaction and potentially decreased costs.


English (en)

Document Type



Abraham, Joanna PhD (Chair) Washington University School of Medicine in St. Louis

Associated Committee

Henrichs, Bernadette PhD, CRNA, CCRN, CHSE, FAANA (Committe Member) Barnes Jewish College, Goldfarb School of Nursing

Included in

Nursing Commons