There have been numerous studies and reports released through the years indicating that inadequate dissemination of information among healthcare providers is detrimental to patient safety. In the acute care setting, the exchange of vital patient information between nurses is endorsed through a shift report; which typically takes place at the nurse’s station. There are many threats to patient safety that could be linked to the process of poor hand off reporting and communication.
Normally, a significant amount of communication takes place during nursing handoff. Sand-Jecklin and Sherman (2014) notes, “The safety of the patient can be compromised at this time” (2014, 2854). Adverse patient outcomes is a very serious matter for healthcare organizations.
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As a result, patient safety is improved and poor outcomes are decreased. Communication of vital information was reported as being more complete among these research. Sand-Jecklin and Sherman (2014) identified an increase in report accuracy and the increase in nurse perceived accountability. This study reported that patient falls during bedside handoff reporting decreased from twenty pre-implementation to thirteen post implementation at 3 months to four at 13 months (Sand-Jecklin and Sherman, 2014). The practice of bedside handoff reporting offers the opportunity to address toileting and other needs thus decreasing the incidents of falls. Kerr et al. (2014) reported that participants in their studies believed that early encounters with their patients during bedside handoff reporting afforded them early assessment of their patients’ condition. This particular finding is relevant to our area, since the deterioration of most of patients condition could be identified during handoff bed reporting. Ultimately, this would improve patient safety and clinical outcome. Jeff et al. (2013) study reported that since bedside handoff reporting provided patients the opportunity to ask questions or clarify concerns. It also serves as trigger for the patient to update caregivers on new developments or concerns. During bedside handoff report nurses are able to assess the clinical environment such as intravenous lines, drainage tubes and infusion flow rates. “Patient reported that they felt safe when experiencing shift report at the bedside” Gregory et al., 2014,
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
Nurses are central to patient care and patient safety in hospitals. Their ability to speak up and be heard greatly impacts their own work satisfaction and patient outcomes. Open communication should have been encouraged within the healthcare team caring for Tyrell. Open communication cultures lead to better patient care, improved outcomes, and better staff satisfaction (Okuyama, 2014). Promoting autonomy for all members of the healthcare team, including the patient and his parents, may have caused the outcome to have been completely different. A focus on what is best for the patient rather than on risks clinicians may face when speaking up about potential patient harm is needed to achieve safe care in everyday clinical practice (Okuyama,
In the nursing profession, communication is a tool to be used effectively in shift-to-shift report to ensure continuity of care and patient safety (Matic, Davidson, & Salamonson, 2010, p. 184). Benson, Rippin-Sisler, Jabusch, and Keast (2007) explain “for a report to be meaningful, the information passed along to the receiver must be done in a way that is effective and efficient; otherwise, the point of communicating the information may be lost” (p. 80). The Joint Commission (TJC) defines barriers in communication as a leading threat to patient safety (Matic et al., 2010, p. 185). Patient safety and continuity of care can be maintained by implementing a handoff communication tool and bedside nurse-to-nurse handoff.
In fact, it is important to the patient’s healing. Before a patient comes to my floor, I look up their history and reasons for admission. This is the gathering or pre-orientation phase. The orientation phase for the bedside nurse would be when the patient arrives on the floor. The nurse introduces their self to the patient and begins establishing trust. The nurse asks the patient questions to see what their expectations are and clarifies the expectations of the hospital or unit. The nurse then explains the plan of care to the patient and answers any questions. In the working phase, the nurse is the patient’s advocate and addresses any problems the patient has. The nurse assures the patient they will research any problems and find out the answers as quickly as possible. Once the nurse finds the answers, he/she relays the information to the patient and the family. He/she may give the patient educational materials, show them a video or simply provide an explanation from the provider. During the resolution phase, the nurse provides discharge information. He/she answers any questions related to discharge and provides the patient with instructions post discharge from the hospital. If the nurse has established a relationship and trust with the patient, the hospital stay and discharge should leave the patient confident that they are well enough for discharge home or to a facility.
Firstly, Nurses must develop the right communication tools when dealing with their patients. For example most nurses do bedside reporting, before they change their shift in the morning, therefore they would be relaying information to the other nurse about the patient they dealt with during the night. The nurse that is going off shift would give a report to the incoming nurse in the presence of the patient. He or she has to discuss the condition of the patient, medications and the procedures so the next nurse would be on the same level. Most nurses in the General Hospital do their reporting by the bedside of their patients.
Furthermore, there should be enough trust between the nurses and physicians where they can easily put aside their egos and ask for a second opinion when they have any doubts concerning a patient's safety. This was clearly exemplified when the nursing staff attending to Lewis Blackman failed to contact the physician when various side effects arose; instead they tailored the signs to fit the expected side effects. Even after Blackman’s health was deteriorating, the nurses remained in their “tribes” and never once broke out of it to ask for help. The entire hospital was built on strong culture of remaining in their tribes instead of having goals oriented towards patients care and safety.
...an be seen that effective communication during handover is essential to providing reliable care (Smith & Pressman, 2010) tailored to a patient's individual needs. As healthcare professionals who can make a difference in life and death for patients, it is therefore crucial to promote active dialogue and exchange of relevant information.
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
Patients Safety is the most crucial about healthcare sector around the world. It is defined as ‘the prevention of patients harm’ (Kohn et al. 2000). Even thou patient safety is shared among organization members, Nurses play a key role, as they are liable for direct and continuous patients care. Nurses should be capable of recognizing the risk of patients and address it to the other multi disciplinary on time.
The first article is, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 34 “Handoffs: Implications for Nurses”, this article is applicable not only to my unit, but every nurse in the profession. It is imperative that the translation of patient information from one person to the next during shift change, patient transfer, or transfer to another facility is clear, accurate, understandable, and complete conveying all pertinent information about that patient. The article discusses why we have problems with handoffs, and different methods for handoff styles. There is no specific hand-off tool that is universal. With that being said it is important that research continues so that possibly in the
The nursing profession is a profession where people put their trust in you to provide care that is not only effective, ethical, and moral, but safe. Not all health situations are simple or by the book. Not all hospitals have the same nurse-patient ratios, equipment, supplies, or support available, but all nurses have “the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm” (ANA, 2009). When arriving at work for a shift, nurses must ensure that the assignment is safe for not only the patients, but also for themselves. There are times when this is not the situation. In these cases, the nurse has the right to invoke Safe Harbor, because according the ANA, nurses also “have the professional right to accept, reject or object in writing to any patient assignment that puts patient or themselves at serious risk for harm” (ANA, 2009).
Varskey, Reller, and Resar (2007) define quality improvement as the desire and drive of an organization to continually improve their procedures, methods, and activities to meet all patient needs (p.736). Although, handoff reporting is something that has already been implemented in many acute care setting, I feel it is a task that is often put on the back burner and not utilized as it was intended. From my experience, when information is missing from the handoff report, many nurses rely on the electronic health records to retrieve information about the previous shift. Although, a majority of this information should be available in the electronic health record and this has helped “improve communications, in some cases they have the opposite effect” (Bailey, 2016, p.1) because of improper documentation and loss of information. I believe that the purpose behind handoff reports was so they could be used much like a “surgical time out”, which allows time for the health team to stop and focus on the patient and their plan of care. Therefore, this video is important to my transition and handoff quality improvement project, because it emphasized proper utilization of a handoff, and showed how it could help a nurse identify aspects of patient care that may have been missed, leading to a better quality of
Patient falls is one of the commonest events within the healthcare facilities that affect the safety of the patients. Preventing falls among patients requires various methods. Recognition, evaluation, and preventing of patient falls are great challenges for healthcare workers in providing a safe environment in any healthcare setting. Hospitals have come together to understand the contributing factors of falls, and to decrease their occurrence and resulting injuries or death. Risk of falls among patients is considered as a safety indicator in healthcare institutions due to this. Falls and related injuries have consistently been associated with the quality of nursing care and are included as a nursing-quality indicator monitored by the American Nurses Association, National Database of Nursing Quality Indicators and by the National Quality Forum. (NCBI)
Despite the frequency of verbal interactions, miscommunication of patient information occurs that can lead to patient safety issues. . . . ‘Effective communication occurs when the expertise, skills, and unique perspectives of both nurses and physicians are integrated, resulting in an improvement in the quality of patient care’ (Lindeke & Sieckert, 200...
Roy L Simpson (2005, January). Patient and nurse safety: How information technology makes a difference. Nursing Administration Quarterly, 29(1), 97-101. Retrieved April 22, 2007, from Health Module database. (Document ID: 815491751).