Communication breakdown is the leading cause of medical errors such as gaps in health care, incomplete or missing information, and medication errors. Most importantly, communication supports the foundation of patient care. So, hand-off reporting during shift change is a critical process that is crucial in protecting a patient’s safety. Throughout the hand-off report, it is vital to provide accurate, up-to-date, and pertinent information to the oncoming nurse. Not only are nurses transferring responsibility, but we are also shepherding and ensuring a safe passage.
Often, shift change is a chaotic period. The phone is ringing. Attendings and a cluster of residents are rounding and subsequently adding twenty new orders that must be implemented before 9 a.m. Eager nursing students are searching for their assigned preceptor, and I discover that the night shift nurse that I am receiving report from is exhausted. She expresses that she had a hard shift and desires to leave the unit before her sanity and patience is tested. So, she provides a brief, unfocused hand-off report and offers no opportunity for questions and irritation ensue at the meager utterance of a syllable or my inquisitive glance. As a result, I am given shattered fragments of the last 12 hours. Yet, I know that I am accountable and responsible for safe, quality, and efficient patient care. Because of this encounter, I have implemented and developed a standardized process throughout my hand-off report.
My preceptor drilled the importance of this task. Moreover, she expressed that this event is vital because it directs the care of my patient, and it is essential that I provide a relevant, timely, and clear account.
- Patient Overview. I give a brief narrative of the shift by providing a broad picture. For instance, I mention critical facts.
- Assessment. The first segment includes the patient’s name, age, gender, allergies, code status, code word, admission history, IV access, and medical history. The second part includes the neurological, cardio, pulmonary, gastrointestinal, genitourinary, skin/ wounds, and musculoskeletal exam. Also, I state critical labs and the most recent vital signs.
- Safety Concerns. I note the patient’s environment and the potential risks that may lead to patient harm (i.e., fall risks).
- Plan of Care. At this point, I share upcoming procedures, patient education, and actionable plans.
- Questioning. I provide the opportunity for questions to ensure communication is clear.
In the end, hand-off reporting is significant. It is our responsibility to ensure that pertinent information is reviewed. All things considered, we are obligated to deliver safe and efficient care.
I encourage you to share your thoughts and experiences. What’s your method for hand-off reporting? I can’t wait to read and learn from your experiences!