Eighty percent of serious medical errors involve breakdowns in hand off communications (South Dakota Medicine, 2014). The hand off risk is not limited to the ED patients (Berger, Sten, & Stockwell, 2012). This is a significant patient safety issue for all patients. The hand offs occur multiple times per day for every patient. These hand offs occur with physician-to- physician, physician-to-nurse, and nurse-to-nurse communications. Each interaction increases the risk of an adverse patient outcome. The use of formatted communication tool like Situation, Background, Assessment, Recommendation/Request, Questions (SBAR-Q) provides a platform for expectations on both sides of the communication interaction. The addition of the I-5 verification tool
