Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

Background: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff.

Methods: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process.