Introduction

This issue of the UPvision Consulting Insights Newsletter explores the critical topic of communication breakdowns during nursing handoffs. Across all care settings, from hospitals to long-term care facilities and beyond, handoff communication plays a pivotal role in ensuring continuity, safety, and quality of care. When these transitions fail, the consequences can be severe, leading to patient harm, legal exposure, and reputational damage for healthcare organizations.

Standards of Care

Effective handoff communication is governed by standards that emphasize clarity, completeness, and timeliness. Key elements include structured formats (e.g., SBAR), verification of understanding, and documentation of the exchange. The Joint Commission and other regulatory bodies mandate protocols to ensure that critical information is not lost during transitions. These standards should be written into agency or organizational policies and procedures and monitored for compliance.

Legal and Case Implications

In malpractice litigation, communication breakdowns during handoffs are often scrutinized to determine breach of duty and causation. Attorneys rely on expert nurse consultants to evaluate whether the handoff met accepted standards and whether the failure contributed to patient harm. Documentation gaps, lack of escalation, and omitted critical information are common issues that can substantiate claims of negligence. Another common issue is failure of the appropriate licensure to perform the hand-off report.

Case Study: Failed Handoff Communication Leading to Harm

Mrs. L, an 81-year-old resident in an assisted living facility, was transferred to a hospital following complaints of abdominal pain. During the hospital stay, she was diagnosed with a urinary tract infection and mild dehydration. Upon discharge, the hospital nurse verbally relayed the discharge summary to the receiving nurse at the facility but failed to document the need for continued hydration and monitoring for infection recurrence.

Over the next 48 hours, Mrs. L's condition deteriorated. Staff at the facility were unaware of the discharge instructions and did not monitor her fluid intake or temperature. She was found unresponsive and readmitted to the hospital with sepsis. The family filed a malpractice claim citing failure to communicate critical discharge information.

Expert nurse reviewers identified that the handoff lacked a structured format, omitted key clinical details, and was not documented. Had the SBAR protocol been used and the discharge instructions documented and verified; the facility staff would have been alerted to the risks and taken preventive measures.

Quality Improvement Strategies

Healthcare organizations can mitigate risks associated with handoff communication by implementing the following strategies:

1. Adopt structured handoff tools such as SBAR or I-PASS.

2. Ensure documentation of all handoff exchanges. Both the giver and the receiver should document that handoff was given, and it was received.

3. Provide training and simulation exercises on effective, bias free, communication.

4. Audit handoff practices and provide feedback.

5. Foster a culture of accountability and verification. The person receiving report should verbalize back to the person giving report their understanding of what was communicated to ensure clarity.

6. Ensure the standard is maintained. Face to Face when possible but not required. An opportunity to ask and answer questions, required.

7. Ensure that the review of historical patient data is included.

Why Legal Nurses Matter

Legal nurse consultants play a vital role in bridging clinical practice and legal standards. For attorneys, they provide expert analysis on merit, identify documentation gaps, and clarify standards of care. For healthcare organizations, they offer assessments of risk, recommend improvements, and support compliance efforts. Engaging legal nurses early in case review or quality improvement initiatives to ensure informed decision-making and strengthens outcomes.

Communication breakdowns during nursing handoffs pose significant risks across all care settings. By adhering to established standards, engaging legal nurse consultants, and implementing quality improvement strategies, attorneys and healthcare leaders can reduce liability, improve patient outcomes, and strengthen case strategy.

Resources and Next Steps

UPvision Consulting, LLC partners with law firms and healthcare agencies to provide expert nurse reviews and bridge the gap between clinical practice and legal standards. Our consultants offer detailed analysis of pressure injury cases and support litigation strategy. Book your case or consultant consultation now https://upvisionconsulting.com/contact-us

Discover everything lawyers need to know, and every healthcare leader should understand, about preventing, documenting, and defending against nursing-related patient safety incidents at the upcoming Attorney’s Resource Conference for sessions on nursing standards of care, expert testimony, and risk mitigation strategies. Register today https://attorneysconference.com/

References

ACOG. (2012, February). Communication Strategies for Patient Handoffs. Www.acog.org. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/02/communication-strategies-for-patient-handoffs

Abraham, J., Kannampallil, T., & Patel, V. L. (2014). A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. Journal of the American Medical Informatics Association, 21(1), 154–162. https://doi.org/10.1136/amiajnl-2012-001351

Joint Commission. (2024). Reducing handoff communication failures and inequities in healthcare. Jointcommission.org. https://www.jointcommission.org/en-us/knowledge-library/news/2024-08-reducing-handoff-communication-failures-and-inequities-in-healthcare

Maria Franco Vega, George, M., Day, L., Anayo Mbadugha, Owens, K., Sweeney, C., Chau, S., Escalante, C., Bodurka, D., & Mohamed Ait Aiss. (2024). Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a Comprehensive Cancer Center. The Joint Commission Journal on Quality and Patient Safety, 50(8). https://doi.org/10.1016/j.jcjq.2024.03.004

‌McCarthy S, Motala A, Lawson E, Shekelle PG. Use of structured handoff protocols for within-hospital unit transitions: a systematic review from Making Healthcare Safer IV. BMJ Qual Saf. 2025 Sep 18;34(10):680-690. doi: 10.1136/bmjqs-2024-018385. PMID: 40306923; PMCID: PMC12232517.

Webster, K. L. W., Keebler, J. R., Lazzara, E. H., Chaparro, A., Greilich, P., & Fagerlund, A. (2022). Handoffs & Teamwork: A Framework for Care Transition Communication. The Joint Commission Journal on Quality and Patient Safety, 48(6-7), 343–353. https://doi.org/10.1016/j.jcjq.2022.04.001