Nurses have been recognized as playing a strategic role in the promotion of patient safety. They spend more time with patients than other health care professionals (HCPs), and the quantity of the time spent has been associated with high-quality care and patient safety.1 By staying close to patients, nurses provide surveillance, which is composed of cognitive and behavioral processes aimed at collecting, monitoring, and summarizing data to detect risks2 and ensure physical presence.1
In recent years, an increased interest for the clinical,3 managerial,4 and research5 aspects of handover models has been documented. Specifically, the debate regards (1) the traditional model of handovers performed away from patients, in which the outgoing and incoming nurses share data in-group, in a dedicated room; (2) the associated bedside shift reports (BSRs), which are designed to provide a patient-centered approach,6 to increase the quality of information shared between nurses7; and (3) the nursing surveillance, which allows nurses to detect in advance clinical and/or cognitive deteriorations.8 As a consequence, several studies have been performed aimed at discovering differences, if any, that occur when nurses perform traditional handovers in a meeting room or at the bedside.9 Moreover, among the different patient safety measures considered by researchers to date, falls have been the main focus and have shown conflicting findings. Therefore, increasing the knowledge available in the field was the main intent of this study.
In one of the first investigations conducted in the field, Athwal et al10 revised the incidence reports aimed at evaluating the changes from the traditional in-group shift report in the conference room to a combination of a written report with a nurse-to-nurse verbal exchange at patients' bedsides. When comparing 2 months before and 2 months after the new shift report, a decreased occurrence of falls emerged. Later, in a study involving 7 units of a teaching hospital, with 232 patients before and 178 after BSR implementation, Sand-Jecklin and Sherman11 reported a decreased rate of falls per month in all units. The decrease in falls in all units was also documented 1 year later by the same research group8 in their quasi-experimental study in which 233 patients received a blended handover (nurses discussed information deemed to be sensitive away from the patient's bedside and then they performed the BSR); after 3 months, 157 patients received a usual handover (the researchers listened to a recorded patient report that was conducted away from patients) and 154 were also evaluated at 13 months post-implementation. Later, Hada et al,12 in their quasi-experimental study on BSR effectiveness, which involved 105 patients (52 in the pretest; 53 posttest), documented a 9.37% reduction in the number of falls without patient harm. Also McAllen et al,13 in their evidence-based practice project aimed at implementing the BSR system, collected data before and after the handover exchange. According to the findings, authors reported a 24% reduction in the number of falls between the 4 months pre- and 4 months post-implementation.
Differently, Taylor14 documented the effects of an evidence-based project using BSRs and walking rounds delivered to 43 patients admitted on a surgical oncology unit. In 2010, they reported an increase in the number of falls, as compared with 2009 (from 25 to 29). Additionally, Malfait et al15 reported an increase followed by a decrease in falls, while the control group reported a reduction in falls followed by an increase. Their project investigated the effects of BSRs by retrospectively analyzing the clinical records of 774 patients (509 actively involved in BSRs vs 265 cared for with a traditional handover).
However, no conclusion regarding the association between falls and handovers performed away from patients or BSRs can be drawn to date: differences in the study designs (prospective vs retrospective); units involved; duration of the observations, which were usually limited to a few months; and sample sizes prevent definitive evidence. Moreover, to date, the evaluations have mainly been performed in projects regarding the BSRs' implementation with the aim of demonstrating its effectiveness. However, no studies have been performed to assess differences, if any, in falls and other patient safety event (PSE) occurrences when nurses are away from patients to conduct their handovers compared with when they are on the unit, thus in a context where no changes or projects are implemented. Therefore, with the purpose of increasing the evidence available in the field, the primary aim of the study was to investigate falls and their severity when they occurred during traditional handovers conducted away from patients as compared with those that occurred when nurses were on the unit. The secondary aim of the study was to analyze the occurrence of other PSEs during the 2 abovementioned periods.
Study design, setting, and definitions
A retrospective study was designed and conducted in 2018 and reported here according to Checklist for Retrospective Data Base studies16 (see Supplemental Digital Content Table 1, available at: https://links.lww.com/JNCQ/A794). The Internal Review Board of the Department of Medical Science of Udine University approved the study (October 3, 2018, 42/IRB_18).
A large academic trust located in the northeast of Italy was approached. This was equipped with 1034 beds and composed of 4 hospitals: (a) a highly specialized hospital with an emergency department and trauma, transplantation, neurosurgical, and cardiosurgical units; (b) 2 community hospitals, including an emergency department and medical, hospice, and residential units; and (c) a rehabilitation hospital composed of 4 postacute and long-term rehabilitation units. These hospitals were connected in a network of services delivering critical, acute, and long-term services under the regulations of the National Health Service. In the years under consideration, 4838 HCPs provided free care to approximately 38932 new admissions per year. The trust also hosted the clinical rotations of physicians and other HCPs (eg, nurses and physiotherapists) for a total of 655 students per year.
In a preliminary fashion, all units were checked for their handover routines: in all, the handover was performed away from the patients in a specific, devoted room that was protected during the handover meetings by closing the door aimed at preventing interruptions, distractions, and ensuring confidentiality of the shared data. Handovers were performed 24/7 3 times a day, from 6:50 to 7:40 am, from 1:50 to 2.40 pm, and from 8:50 to 9:40 pm. In the first 10 minutes, the ongoing nurses briefly recorded data in the nursing records and prepared the handover exchange process. In the remaining 40 minutes, the in-group (nurses and nurses' aides) handed over the information. The BSR was performed only in some critical care units.17 In the approached trust, the incident reporting system was introduced in 200318 as a system where all HCPs are invited to report all PSEs occurring in the practice. A PSE is “any event which resulted in, or could have resulted in, unintended harm to a patient by an act of commission or omission, not due to the underlying medical condition of the patient.”19 The incident reporting form has been introduced as anonymous and voluntary with the exception of falls that have been mandatory since 2011.20 Over the years, initiatives of continuing education to HCPs of all units and to newly recruited professionals were offered aiming at ensuring homogeneity on data reporting.
The incident reporting form has been based on structured items aimed at collecting data regarding the following aspects: the event affecting the patient's safety; when it has occurred (eg, month, day of the week, and hours); and its full description (eg, context, what happened just before and after). A box containing the forms was available; the box also contained the procedures to undertake describing when and how to fill it and to whom to send it as the Clinical Risk Unit of the trust. The Clinical Risk Unit was responsible for data processing, which was (a) first, according to the relevance of the event reported, in which case the staff was appointed to decide and undertake the immediate responses (eg, providing an audit); and (b) second, they were also responsible for recording all events in the database, on a daily basis. The database was also analyzed on an annual basis, and the report disseminated at the trust level in meetings aimed at stimulating critical reflection on the practice.
The database where the PSEs are recorded (from 2013 to 2017 = 5 years) was analyzed. Data regarding patients admitted in one of the units of hospital where nurses were used to perform handovers away from the bedside, and that fell in the period under study were included. Therefore, data regarding PSEs occurring to (a) patients cared for in day hospital facilities, operating rooms, ambulatory settings, intensive care units, or emergency departments, or in outpatients' facilities; (b) visitors (eg, family members); and (c) volunteers were excluded. Also PSEs not reporting the hour when they occurred were excluded. Therefore, from the initial database of 8255 PSEs, a total of 3780 were excluded. Of these, 396 occurred to visitors, outpatients, or volunteers, and 590 were excluded because the time when they occurred was missing.
Data extraction and bias control
From the database we extracted (a) the PSEs; (b) the information regarding when they occurred: during handovers, after handovers, or during other times when nurses were on the unit; and (c) in the case of falls, the severity of their consequences if they were categorized as none, injury, or death. Each PSE was categorized by 2 researchers as falls or other events. Other events were then categorized according to the International Framework for Patient Safety of the World Health Organization,21 as reported briefly in Supplemental Digital Content Table 2 (available at: https://links.lww.com/JNCQ/A795). Specifically, falls have been categorized in an additional category, leaving those including patient accidents as containing the remaining events.
Specific strategies to prevent information and selection bias, sponsor bias, and team lead bias22 were adopted. On a preliminary fashion, we assessed the consistency in the reporting/coding system over the years in the incident reporting forms adopted by the trust. Then all records regarding PSEs that occurred to patients who were admitted in hospital and during their in-hospital stay were considered. Moreover, only those records reporting exactly the hour when PSEs occurred were included. Furthermore, only data that had been recorded in the official databases were considered, and links between the annual databases were performed by 2 researchers whose aim was to prevent errors. For what concerns the HCPs filling in the incident report form, we ensured that procedures and training were both homogenous over the years, thus providing a common set of references in the procedures. We also checked to see whether incentives or disincentives were used over the period under study that encouraged or discouraged to fill in the incident form, and no strategies emerged.
Data collected were assessed, anonymized, and processed, and the statistical analyses were conducted using the IBM SPSS software v. 24 (IBM Corp, Armonk, New York). On a preliminary fashion, since in 2013 the number of events was much smaller than in the following years, and since we could not exclude the fact that there was also some degree of reporting bias, we conducted an additional assessment after excluding events that were reported in the first year, as a sensitivity analysis. The results did not change after excluding events reported in 2013.
Thus, a descriptive statistical analysis was performed, and frequencies, percentages, and incidence rates with a confidence interval (CI) of 95% were calculated. Considering that the overall daily duration of nurses' handovers was 150 minutes, in the 5 years of study there were, over all, about 4565.6 hours during which nurses were involved in handovers and 39 264.4 hours during which they were available at the patient's bedside. Given that each day the number of patients in a hospital unit was substantially the same during handover times and during the rest of the day, we calculated the number of reported falls per hour, both during handover times and during the rest of the day. The statistical significance was P < .05.
Falls and patient safety events occurrence
There were 3489 PSEs emerged: 1966 (56.3%) falls and 1523 (43.7%) other PSEs. Among the latter, unspecified events prevailed (403; 11.6%) followed by those regarding clinical administration (191; 5.5%), medication/intravenous fluids (187; 5.4%), and documentation (175; 5.0%) (see Supplemental Digital Content Figure 1, available at: https://links.lww.com/JNCQ/A796).
The number of reported falls during the years varied. The lowest number was reported in 2013 with 350 (17.8%) falls, while the highest was reported in 2014 with 434 (22.1%) falls. Similarly, the number of PSEs also varied, from 77 (5.1%) reported events in 2013 to 440 (28.9%) in 2015 (Table 1).
Table 1. -
Falls Other PSEs that Occurred During Handovers vs.
Not During Handovers Times
||PSEs n = 3489 n (%)
||Handover Times n = 358 (10.3%) n (%)
||Nonhandovers n = 3131 (89.7%) n (%)
|Fall occurrences, years
|Other PSE occurrences, years
|From Monday to Friday
|Falls, reported by
Abbreviation: PSEs, patient safety events.
aStatistical significance was considered at P < .05.
Among the 1966 falls, 226 (11.4%) occurred during handovers and 1740 (88.6%) during nonhandover times. The majority of falls were reported on weekdays, from Monday to Friday (1452; 73.9%), and they happened significantly more often during nonhandover times (1280; 73.6%) as compared with during handovers (162; 71.7%) (P = .006). On the other hand, on weekends, the occurrence of falls was higher during handovers (64; 28.3%) as compared with those that occurred during nonhandover times (460; 26.4%) (P = .037). Furthermore, falls occurred more often during night shifts (901; 45.8%) than during morning (572; 29.1%) and afternoon shifts (493; 25.1%). However, during the morning and afternoon shift handovers, falls happened significantly more frequently (83, 36.7%, respectively) compared with those happening in the same shifts during nonhandover times (489, 28.1% and 410, 23.6%, respectively). Night shifts also had a significantly higher occurrence of falls (841; 48.3%) (P = .006). All PSEs were reported mainly by nurses (1786; 90.8%), both when they occurred during handovers (205; 90.7%) and when they did not (1581; 90.9%) (P = .861) (Table 1).
Fall incidence and severity
The incidence of falls every 100 hours was 4.9 (95% CI, 4.3-4.6) during handovers and 4.4 (95% CI, 4.2-4.6) (P = .11) during nonhandover times (Table 2). Regarding other PSEs the incidence rate was 2.9 (95% CI, 2.4-3.4) during handovers and 3.5 (95% CI, 3.4-3.7) (P = .025) during nonhandover times (Table 2). The distribution of the reported falls according to the outcome severity was homogeneous as no injuries (during handovers = 145; 64.2% vs nonhandover times = 1125; 64.7%), injuries (80; 35.4% vs 608; 34.9%, respectively), and deaths (1; 0.4% vs 7; 0.4%, respectively) (P = .95) (Table 3).
Table 2. -
PSEs Incidence/100 Hours During Handover Versus During Nonhandover Times
||Reported PSEs n (%)
||Overall Hours n
||Events/100 h (95% CI)
Abbreviations: CI, confidence interval; PSEs, patient safety events.
aStatistical significance was considered at P < .05.
Table 3. -
The Distribution of the Reported Falls According to the Outcome Severity
||Handover Times n (%)
||Nonhandover Times n (%)
More than half of all PSEs reported in the database over the 5 years were falls. Considering the duration of the study of 5 years, around one fall per day (1966/365 × 5) occurred while other PSEs occurred less frequently, which confirms that falls are the most frequent adverse event.23 Moreover, given that the trust was equipped with 1034 beds (1034 × 365 × 5 = 1 887 050), there were around 1.04 episodes/1000/beds/day, which is slightly inferior to previously documented findings: from 2.6 to 7 episodes/1000/beds/day.23
Based on a raw analysis, falls have occurred significantly more often during handovers than during nonhandover times; however, the findings seem to reflect a pattern where falls occur mainly while nurses have handovers during weekends, which contrasts with the occurrences the happened from Monday to Friday. Furthermore, despite available evidence,1 falls seem to occur homogeneously during morning and afternoon handovers and more often than during night shifts. Different lines of interpretations can justify these findings. First, during handovers, nurses are away from the patients, which might lower the surveillance required to detect their patients' risk of falls. Second, during weekends, the nurse-to-patient ratio is the lowest because hospitals reduce their diagnostic and operating room services, reserving them for urgent conditions,24 thus the estimated need of nurses is low. Third, despite nights having been documented as the highest risk for falls1 due to the poor nurse-to-patient ratio, with a higher occurrence of confusion/agitation,25 related sedative administrations,26 and poor lighting of the rooms,27 patients seemed to have a similar risk of falls as that during handovers performed in the morning and afternoon. During these handovers, which reflect the end of lunch and dinner, respectively, patients may have several needs that they try to manage alone without the help of the nurses who are away to perform the handovers. On the other hand, according to Abreu and colleagues,25 falls occurring in the morning and late afternoon may reflect the consequences of several activities performed to satisfy patients' fundamental needs (eg, moving from the chair to the bed and going to the toilet after lunch or dinner).
At the analysis of incidences, during handover times, a slightly higher number of falls per hour emerged than during nonhandover times (4.9 vs 4.4) although the difference was not statistically significant. Inpatient falls have been documented as a multifactorial complex phenomenon involving clinical, environmental, and organizational factors, in addition to patient-to-nurse interactions.28 Falls occurring during handovers might be called “unassisted falls” because they occur when nurses are away from patients and likely not active in their surveillance, thus incapable of detecting fall risks in advance.1 However, although a merit to further studies,29 the nurses' presence on the unit seems in our study as in previous (eg, Staggs and Dunton30 and Lake et al31) not to protect patients from falls. Moreover, during nonhandover times, the incidences of other PSEs have emerged as significantly higher than those that occurred during handovers (3.5 vs 2.9). This can be explained by the increased exposure of activities and procedures (eg, medication administration) that may increase the risks for patient safety. On the other side, during handovers, the exposure to procedures is limited to critical patients, given that nurses have the priority to share the nursing records.
At the analysis of the findings of the severity of falls, no significant differences have emerged between falls occurred during handovers and during nonhandover times (34.9% vs 35.9%). Around one-third of falls, irrespective of when they occurred, resulted in a slightly greater injury than one previously reported, ranging from 0.7% to 30%.32 The majority of falls related to injuries caused minor to moderate negative patient outcomes, while those resulted in fatal consequences are in line with previous studies.33
The emerged findings should be considered in the light of study limitations. This was a large study using a database established in a large academic hospital, with more than 1300 beds, that was developed for purposes other than research; therefore, the quality of data might have influenced the study findings. Data were analyzed at the hospital level. Although handover practices have been assessed for their main features as being homogenous across the units, some variations might have affected the findings over the years. As documented previously34 and according to the retrospective nature of the study, a systematic underreporting might have affected the accuracy of the database. Furthermore, a database populated by PSEs documented, for the most part, by nurses was accessed. Given that handovers imply the involvement of incoming and outgoing nurses away from patients, in a protected environment, some safety events might not have been reported because they were unrecognized. Lastly, falls and fall-related injuries have been associated with the nursing environment of the unit and the hospital characteristics (eg, size, magnet, or teaching status)28; therefore, further studies comparing setting-specific factors for falls are recommended.
This study has compared the incidence and the severity of falls as a primary outcome, and the incidence of other PSEs among hospitalized patients in a large Italian academic trust, as reported when nurses attend handovers away from the patients' bedside and when they are on the floor, as a secondary outcome. To our best knowledge, this is the first study on a large scale that has compared the daily practice of nurses regarding handovers away from patients, without introducing changes.
No differences emerged in the occurrence of falls during handovers performed away from patients and when nurses were on the unit. Moreover, no differences emerged in the outcome severity of occurred falls between handovers and nonhandover times. Furthermore, other PSEs decreased in occurrence during handovers as compared to other moments during the shifts. However, during handovers performed in the morning, afternoon, and on weekends, a higher occurrence of falls emerged, which suggests the need to potentiate nursing surveillance and to investigate the underlying factors that increase the risk of falls.
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