Department: CLINICAL QUERIES
Lorenzo Ortega is a recent graduate of California State University Sacramento, where Bridget Parsh is an assistant professor of nursing.
The authors thank California State University Sacramento for encouraging student authorship.
The authors have disclosed that they have no financial relationships related to this article.
Shift change is crazy on our unit because everyone's so busy. Do you have any tips for improving the process?—M.J., OKLA.
Lorenzo Ortega, BSN, and Bridget Parsh, EdD, RN, CNS, reply: Patient handoffs at shift change seem routine, but during this transfer, vital nursing, medical, and personal information passes through multiple care providers in a short time. The potential for an information gap causing an error is very real. (For news about recent research, see “Patient handoffs: Who gets shortchanged at shift change?” on page 21.)
The Joint Commission has identified communication as the primary cause for preventable medical errors, with handoffs accounting for 80% of these instances.1 Because the handoff lays the foundation for a nurse's shift, any discrepancy from the true clinical picture can be devastating. These steps are vital to an effective handoff:
Communicate clearly. Effective communication is a dynamic process in which questions are asked and concerns are voiced.2 Less-experienced nurses may fail to question or clarify a report from a more-experienced colleague.3 Remind staff to advocate for patients during handoff by giving and receiving a clear report.
Focus and avoid distractions. When nurses give report, their fatigue and stress can lead to information being omitted. Unfortunately, many handoffs take place under tight time constraints and with distractions such as phone calls, patient call lights, and family questions.1 Encourage outgoing nurses to start handoff report shortly before the shift ends by writing a brief summary to help organize thoughts and avoid misinformation.1
Make drug information a priority. Information about the medications prescribed, administered, and not administered is vitally important during handoff.4 Knowing why a patient has been prescribed certain medications goes a long way to understanding the patient's clinical status and providing a safe environment. For example, acetaminophen is commonly prescribed for pain and fever, so take a moment to calculate the amount given in 24 hours to prevent an inadvertent overdose. This step takes only a few moments but can prevent liver failure.4
Report at the bedside. One of the best ways to prevent confusion and misinformation is to conduct the shift handoff report at the patient's bedside. Bedside report is a good time to conduct an initial shift assessment and include the patient and family (if available and if the patient has given permission). Not only can bedside report save time, it also lets the nurse connect with the patient.5 Any inconsistent information given in the report can be clarified by the patient and family, who consequently feel more included in caregiving. Enhance patient safety by confirming identification and allergy bands, I.V. fluids, and the medication administration record right at the bedside.5
Consider a checklist. With all the information to cover during handoff and tasks to be completed during assessments, nurses can become overwhelmed with heavy patient assignments. Using a quick handoff assessment tool at the bedside can prevent errors in a systematic manner.
Some of the most useful handoff tools correspond to a head-to-toe assessment, with blank spaces for systems to help organize a patient's care. Within each system, more detailed information can be provided; for example, in the neurologic section, the Glasgow Coma Scale score, pupillary light responses, and intracranial pressure. A handoff tool could also include scheduled procedures, most recent lab data, or medication administration times.
Involve the entire staff when tackling handoff improvement on your unit. Consider what's working well and what might be improved. Nurses are more accepting of changes to handoff if they're involved in the development or choice of tools.6 Every nursing unit is unique—find ways to improve shift change that work for your patients and your staff.
1. Popovich D. 30-Second Head-to-Toe tool in pediatric nursing: cultivating safety in handoff communication. Pediatr Nurs. 2011;37(2):55–59.
2. Reid J, Bromiley M. Clinical human factors: the need to speak up to improve patient safety. Nurs Stand. 2012;26(35):35–40.
3. White N. Understanding the role of non-technical skills in patient safety. Nurs Stand. 2012;26(26):43–48.
4. Don't let children suddenly deteriorate during handoffs: use proven practices. ED Nurs. 2011;14(10):109–111.
5. Street M, Eustace P, Livingston PM, Craike MJ, Kent B, Patterson D. Communication at the bedside to enhance patient care: a survey of nurses' experience and perspective of handover. Int J Nurs Pract. 2011;17(2);133–140.
6. Alvarado K, Lee R, Christoffersen E, et al. Transfer of accountability: transforming shift handover to enhance patient safety. Healthc Q. 2006;9(Spec No.):75–79.
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