Are dangerous errors occurring during change of shift? Use these strategies
Are dangerous errors occurring during change of shift? Use these strategies
Handoffs’ are most dangerous time in EDs
(Editor’s note: This is the first of a two-part series on improving "handoff" communication in EDs. This month’s story focuses on change of shift. Next month, we’ll cover handoffs involving patients being transported from the ED to other areas of the hospital, including diagnostic testing and inpatient units.)
After a stressful 12-hour shift in the ED, have you ever forgotten to tell the oncoming nurse about a patient’s pending lab test results, pain medications given but not documented, the fact that a medication is hung on an intravenous pole but not yet infused, or the need for contact precautions?
"Change of shift is the riskiest time in the ED, as the handoff process is not perfect and information may be lost," warns Patricia Scott, RN, BSN, CEN, former ED director at Martin Memorial Medical Center in Stuart, FL.
If key pieces of information are missed, this can result in problems ranging from patient dissatisfaction to major adverse events, says Trisha Flanagan, RN, MSN, CEN, ED nurse manager at Beth Israel Deaconess Medical Center in Boston. "This is particularly true in the chaotic environment of the emergency department," she says. "Our nurses give report in the clinical area, where they can be interrupted and distracted by patients, their families, and medical staff."
Communication lapses were the No. 1 root cause of sentinel events reviewed by the Joint Commission on Accreditation of Healthcare Organizations from 1995 to 2004. As of Jan. 1, 2006, a newly added National Patient Safety Goal will require a standardized approach be used for handoffs, with an opportunity for staff to ask and respond to questions.
Handoffs are an especially high-risk time in EDs, due to factors including high volumes and the nursing shortage, says Peter Angood, MD, vice president and chief patient safety officer for the Joint Commission’s International Center for Patient Safety. "The ED is a highly complex environment with a constellation of pressures that create the opportunity for adverse events and errors to occur," he says. "With the combination of communication lapses and not fully trained staff, there is a strong potential for errors to occur during handoffs."
Red flags that an ED isn’t complying with the goal’s requirements include use of tape recorders to give report, illegible handwriting, use of nonstandardized forms, and the inability to contact a nurse for follow-up if needed, says Angood. "Ideally, there should be a good face-to-face communication," he says.
To improve communication during change of shift, consider these strategies implemented at EDs:
•Create a protocol.
At Beth Israel Deaconess, the ED nurse manager, clinical educator and ED nurses created a "safe handoffs" protocol for change of shift. "Our goal is to reduce the risk that critical information is overlooked or omitted when patient care is passed from one nurse to the next," says Flanagan. The protocol requires oncoming and off-going nurses to review the following:
— critical interventions such as medications administered, vascular access, cardiac monitoring, and oxygen saturation;
— communication including cognitive status and hearing/visual aids;
— psychosocial needs, family needs, and location of family members or visitors;
— dual verification with two patient identifiers;
— code status;
— precaution status;
— injury risk;
— plan of care and the patient’s understanding of plan of care;
— the patient’s belongings accounted for;
— need for specialized equipment such as bariatric or padded side rails;
— equipment checks completed.
"For the first month as we roll this out, we plan to have leadership presence on the unit during our two biggest shift changes, 7 a.m. and 7 p.m.," says Flanagan. "I think that our support will help staff work through what is a new process for shift change while ensuring compliance and identifying any barriers that exist."
Senior ED nurses who helped design the protocol will act as informal peer leaders and assist in the education and implementation processes, adds Flanagan.
• Switch to electronic documentation.
Lori Pelham, RN, clinical nursing supervisor for the ED at University of Michigan in Ann Arbor, says that staff members give report to each other in front of a computer. "We can pull up all of our documentation related to that patient while we are talking to each other," Pelham says. "This includes triage notes, assessment, and even past records."
Since implementing an electronic tracking board at Northwest Community Hospital in Arlington Heights, IL, the ED nurses can easily view the primary nurse assigned for all patients. "This has eliminated communication gaps at shift change, and ensures that all patients are accounted for,’ including those that arrive during the shift change," says Sharon Chesney, RN, MS, clinical specialist for the ED.
Now, the tracking board lists an assigned nurse for each patient, and at change of shift, the oncoming nurse must log in and assign herself to the patients she is responsible for, she says. "We now quickly skim the board to confirm that each patient has an assigned nurse, and that the nurses that are assigned are on duty.’"
•Use a checklist.
At Paradise Valley Hospital in National City, CA, a checklist was created for ED nurses to document key pieces of information at changes of shift. Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, director for emergency services, says "That prompts them so they don’t forget anything. And since they are signing off on it, it gives them accountability." (See the ED’s checklist.)
The checklist reminds nurses to follow up with work orders for equipment in need of repair or replacement. "For example, if a monitor has to be off the unit for a day because they are fixing it, the nurse writes `The portable monitor in Room 2 is in Biomed,’ so the oncoming nurse doesn’t wonder where the monitor is," says Baker.
Previously, charge nurses sometimes forgot to tell oncoming nurses about pending lab results, says Baker. "It’s not because any of us are trying to be inconsistent," she says. "It’s just that there is so much to remember, and those were getting missed." The form gives accountability that they have done it, Baker says.
The checklist also reminds nurses to check for X-ray results that are pending, in the event that the radiologist sees something the following day that the ED physician missed, says Baker. "Also, portable phones were constantly being lost because nobody had accountability," she adds. "With the checklist, nurses now make sure both charge nurse phones are there."
•Have the off-going charge nurse give a brief overview to oncoming nurses.
In addition to giving a full report to the oncoming charge nurse, a "shift report huddle" is done with nurses coming on shift, says Baker. "After the oncoming charge nurse makes assignments, those nurses go directly to check the rooms to make sure all equipment is in working order, before they even get report from the outgoing nurses," she explains. "We have found that if you delay doing that until later in the shift, you get busy and never get to it."
•Do "walking rounds" with oncoming nurses.
Walking rounds are much more effective than verbal reports, says Baker. "It introduces the new nurse to the patient, and they can verify that all the charting was done," she says. "If any medications are missing but not charted, you can ask if they were actually given."
At Martin Memorial’s ED, the following is done during walking rounds:
— The new nurse is introduced to the patient. For example, the patient is told, "Mr. Jones, we are changing shifts and reviewing the care plan for all of our patients. This is Mary Johnson. She is your nurse for the next shift."
— At the bedside, the patient’s identity is confirmed using two identifiers.
— An oral report is given to confirm the plan of care. "By reviewing the patient chart during walking rounds, any missing information such as history, allergies, or treatments can be corrected," Scott says.
Sources
For more information on "handoff" communication during change of shift, contact:
- Stephanie J. Baker, RN, BSN, CEN, MBA/ HCM, Director, Emergency Services, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Telephone: (619) 470-4386. E-mail: [email protected].
- Sharon Chesney, RN, MS, Clinical Specialist, Emergency Department, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-1000, ext. 4063. Fax: (847) 618-4098. E-mail: [email protected].
- Trisha Flanagan, RN, MSN, CEN, Nurse Manager, Emergency Department, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215. Telephone: (617) 754-2315. E-mail: [email protected].
- Lori Pelham, RN, Clinical Nursing Supervisor, Emergency Department, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Telephone: (734) 647-7565. E-mail: [email protected].
- Patricia Scott, RN, BSN, CEN, Emergency Department, Martin Memorial Medical Center, 300 Hospital Ave., Stuart, FL 34994. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.