RESUMO
BACKGROUND: Handoffs can pose risks to patients. LOCAL PROBLEM: Nurses throughout a children's hospital understood patient handoffs differently, resulting in handoff errors (failures) across departments. METHODS: Lean principles were used to modify and implement the ISHAPED (Introduction, Story, History, Assessment, Plan, Error Prevention, and Dialogue) tool. INTERVENTIONS: The team implemented a modified ISHAPED (m-ISHAPED) tool to align the content shared and the expectations for interdepartmental handoff. RESULTS: Improvements were seen in reported patient safety events from 6.84 to 1.57 per 100 patient days (P < .001) and nurse satisfaction from 81.1% to 90.6% (P < .001). CONCLUSIONS: A standardized process for interdepartmental nursing handoff was successfully implemented.