Nurse Change-of-Shift Report/Nurse Handoff

Nurse Change-of-Shift Report/Nurse Handoff Policy Statement

Errors in communication have been found to be the leading root cause of sentinel events among healthcare facilities in the United States (4), (6). It is our intention to provide the highest quality of care possible to our residents. To decrease errors in communication and thus improve quality of nursing care and ensure the safety of our residents, nurses will follow a policy for standard change-of-shift reporting/nurse handoff report. Change-of-Shift Report is defined as a nursing intervention from the Nursing Interventions Classification (NIC) defined as exchanging essential patient care information with other nursing staff at change of shift (4). A sentinel event is defined as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient' s illness (5).

Scope
Skilled Nursing and Long Term Care

Policy Interpretation and Implementation

1. A change-of-shift report/handoff report between nurses will take place at each shift change, when a nurse is transferring a resident to the emergency room, when a resident is being discharged, when a resident is moving to a new unit within the facility, and when the nurse is changing units (2). Report will be conducted at the time of shift change, between nurses, prior to caring for residents. All nurses will use a report form as a tool for giving and receiving report. The 24 hour report sheet will also be used each shift to improve communication between shifts. Report can be given verbally or recorded. Recorded reports must still allow for the opportunity for questioning between the giver and receiver of resident information (2). This means the off-going nurse may not leave the unit until the recorded report has been listened to by the oncoming nurse. Report will be given in an area with limited interruptions (3). Included in report for each resident should be up-to-date information regarding the residents care, treatment and services, condition, and any recent or anticipated changes (1), (2), (3), (4), (6). The report may include but is not limited to: Name Age Diagnoses- reason for admission Medicare or long term care Past medical history relevant to current situation Complications Patient/family goals or issues Teaching needs Order changes Upcoming appointments or consults Medication administration (i.e., how the resident takes pills, what medications were refused or held) Infection control issues Discharge plan notes Pain levels Vital signs Date of last BM Diet Systems assessments/stop and watch Skin issues (i.e., Dressings when last changed and their location)

2. 3. 4.

5. 6.

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Nurse Change-of-Shift Report/Nurse Handoff

Policy Interpretation and Implementation Continued

Labs and diagnostics Care plan changes Therapy notes Safety concerns Miscellaneous concerns Anything left undone from your shift that needs to be completed

References: (1). Alvarado, K., Lee, R., Christoffersen, E., Fram, N., Boblin, S., Poole, N.,Forsyth, S. (2006). Transfer of accountability: Transforming shift handover to enhance patient safety. Healthcare Quarterly, 9. Retrieved from http://www.hqontario.ca/portals/0/Modals/qi/en/processmap_pdfs/resources_links/Transfer%20of%20Account ability.pdf (2). Friesen, M. A., White, S. V., & Byers, J. F. (2008). Handoffs: Implications for nurses. In Hughes RG (Ed.), Patient safety and quality: An evidence-based handbook for nurses (2-285-2-332). Rockville, MD: Agency for Healthcare Research and Quality (US). (3). Ortega, L., & Parish, B. (2013). Improving change-of-shift report. Nursing2014, 43, 68. doi: 10.1097/01.NURSE.0000425873.18314.92 (4). The Joint Commission. (2007). Improving Americas hospitals: The Joint Commissions annual report on quality and safety. Retrieved from http://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf (5). The Joint Commission. (2013). Sentinel event. Retrieved from http://www.jointcommission.org/sentinel_event.aspx (6). The World Health Organization. (2007). Communication during patient hand-overs. Patient Safety Solutions, 1(3). Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf

Date: Date: Date: Date:

By: By: By: By:

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