According to a sentinel event statement issued by The Joint Commission in 2017, inadequate hand-off communication is responsible for many adverse-events, including sentinel events in healthcare. A study released in 2016 estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years(The Joint Commission [TJC], 2017). Successful handoff communication has the potential to substantially improve patient safety when leadership displays their commitment to successful handoff, when handoff is standardized and done face-to-face between healthcare providers, when handoff is done in a location free from interruption, when training has been conducted on proper handoff techniques, when the success of handoff is monitored, and if high-quality handoff is made a priority (TJC, 2017). The current process of post-operative handoff in this facility does not comply with The Joint Commission’s recommendations and displays a need for change. In order for post-operative handoff between the operating room and the post-anesthesia care unit to be effective and promote patient safety, a standardized method of giving patient report must be implemented. I am proposing a project that will monitor the implementation of a standardized Post-Operative Handoff (POH) tool to be used when a patient is moved from the Operating Room (OR) to the Post-Anesthesia Care Unit (PACU) in order to improve the quality of POH in our facility. This project will occur in 3 phases, with phase 1 consisting of anonymous auditing of current POH procedures to identify breakdowns in communication, phase 2 will involve education of OR staff, PACU nurses, and administration on the use of a standardized POH tool to guide report, and phase 3 will consist of another round of POH audits to determine if the POH tool has been effective.

Date of publication

Spring 4-20-2021

Document Type

MSN Capstone Project



Persistent identifier



Masters of Science in Nursing Education