Nurses' Association Uses AHRQ's TeamSTEPPS® in Patient Handoff Toolkit

Patient Safety
January 2010

As part of its "Patient Safety First" program, the Association of periOperative Registered Nurses (AORN) developed a Patient Hand-Off Tool Kit based on Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®). TeamSTEPPS was produced by the Department of Defense in collaboration with AHRQ.

AORN customized the TeamSTEPPS materials for the perioperative environment to improve communications between surgical team members by providing standardized "hand-offs." The perioperative Patient Hand-Off Tool Kit includes a summary of the evidence-based research on patient hand-offs, sample patient hand-off templates, and a PowerPoint presentation on standardizing hand-offs.

Robin Chard, PhD, RN, CNOR, says, "The patient safety initiative at AORN started with our Patient Safety First program. The program was launched in 2002 to help our members meet The Joint Commission's National Patient Safety goals. Given that problems in communication cause the majority of avoidable adverse events, we included the TeamSTEPPS resource to specifically improve transitions in care within the perioperative environment."

The Patient Hand-Off Tool Kit is available free of charge to the general public and AORN members on the AORN Web site at

Though the organization does not keep specific data on the utilization or implementation of its Patient Hand-Off Tool Kit resources, its Web site was accessed almost 20,000 times during 2008 and 2009.

Chard adds, "Our membership has specifically praised the examples of structured tools that facilitate consistency in communication exchanges, such as the mnemonics, 'I PASS THE BATON' and 'I-SBAR.' These tools help our members safely move patients from the preoperative environment to the operating room to recovery to the inpatient setting or to home."

With over 42,000 members nationwide, AORN provides resource-sharing and networking and is committed to improving patient safety in the surgical setting.

Impact Case Study Identifier: 
AHRQ Product(s): TeamSTEPPS®
Topics(s): Patient Safety
Geographic Location: National
Implementer: Association of periOperative Registered Nurses
Date: 01/01/2010
Page last reviewed October 2014