SWITCH for Safety: Perioperative Hand-off Tools

Communication breakdown is the leading cause of reported sentinel events in the perioperative setting. Barriers to optimal communication include noise, stress, multitasking, and rapid turnover between procedures. AORN has identified communication during personnel changes (ie, hand offs) as a point of vulnerability for the surgical patient. A standardized hand-off method provides an opportunity for personnel to ask and answer questions and should be available in the perioperative setting. At one facility, the standardization of hand-off reporting resulted in the development of new hand-off tools specific to the perioperative environment. A standardized reporting method enabled health care providers to address communication barriers and to maintain their focus on the patient during critical moments (eg, shift changes), thereby improving patient safety.