Handover. Pilot study to show the loss of important data in nursing handover

Department of Otolaryngology, Gloucester Royal Hospital, Gloucester.
British journal of nursing (Mark Allen Publishing) 11/2005; 14(20):1090-3. DOI: 10.12968/bjon.2005.14.20.20053
Source: PubMed


A good nursing handover process is a crucial part of providing quality nursing care in a modern healthcare environment. The conservation of patient data during the handover process is vital to ensure good continuity of care and safe practice. Any errors or omissions made during the handover process may have dangerous consequences. The authors observed the handover of 12 simulated patients over five consecutive handover cycles between nurses. Three handover styles were used and the amount of data loss was recorded for each style. A purely verbal handover style resulted in the loss of all data after three cycles. A note-taking style (the traditional style used in most hospital wards) resulted in only 31% of data being transferred correctly after five cycles. When a typed sheet was included with the verbal handover, data loss was minimal. Current handover methods may result in significant loss of important data that may impact on patient care. The authors recommend that prior to handover, a formal handover sheet be constructed that can be transferred as part of the handover process.

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    • "The longer a patient spends in the ED, the more likely they are to experience a SC. Inadequate communication during a handoff at SC can lead to medical errors and worse patient outcomes[5]. This study explores the association between ED nursing SC and ED LOS on the outcomes of patients with ICH. "
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    ABSTRACT: Objectives: Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods: Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08-6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results: Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4-6 (OR 3.638, 95% CI 1.531-8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491-6.236, and P = 0.0023) but not death. Conclusions: Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.
    Full-text · Article · Oct 2015
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    • "Just as communication about medication helps to ensure patient safety, communication at patient handovers requires conservation of patient data to ensure good continuity of care and safe practice. Errors or omissions during handovers may have severe consequences [6] "

    Full-text · Article · Oct 2013 · International Journal of Medical Informatics
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    • "Literature Sources Standardization Solutions for Handoff Problems Procedures Medium Data clinical pathway (*) 5 rights, sign-outs memory aids, (acronyms, checklists) low-tech, e.g.: white-boards, type-written, written + spoken hybrid (hi+low tech) clinical systems (**) (CPOE, EMR, etc.) audit and verification Panella and Vanhaecht 2010, Vanhaecht et al. 2009, Montori and Guyatt 2008, De Bleser et al. 2006, Claridge and Fabian 2005, Doherty 2005, Guyatt et al. 2004, Whittle et al. 2004 X Wurmb et al. 2008 X X Cohen and Hilligoss 2010 X X X Haynes et al. 2009, Quin et al. 2009 X X Arora 2009 X X Gawande 2010, Weiser et al. 2010, Belfrage et al. 2009, Philibert and Leach 2005 X Clark et al. 2009, Hatten-Masterson and Griffiths 2009, Porteous et al. 2009, Patterson 2008, Catchpole et al. 2007, Kelly and Berger 2006, Patterson et al. 2004 X Sehgal et al. 2010 X Aron et al. 2011, Shim and Kumar 2010, Ash et al. 2009, Berente et al. 2009, Campbell et al. 2009, Reckmann et al. 2009, Ash et al. 2007, Kramer et al. 2007, Campbell et al. 2006, Poon et al. 2006, Cheah et al. 2005, Koppel et al. 2005, Ash et al. 2004, Laguna and Marklund 2004, Grover and Malhotra 1997 X Pothier et al. 2005 X Arora et al. 2009 X Barnsteiner 2008, Smith et al. 2008, McFetridge et al. 2007 X Streitenberger et al. 2006 X Steinberger et al. 2009 X X Wayne et al. 2008, Solet et al. 2005 "
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    ABSTRACT: Purpose ‐ The purpose of this paper is to examine how clinical handoffs affect clinical information quality (IQ) and medication administration quality. Design/methodology/approach ‐ A case study was conducted in a US hospital. The authors applied a business process management (BPM) perspective to analyze an end-to-end medication administration process and related handoffs, and accounting control theory (ACT) to examine the impact of handoffs on IQ and medication errors. Findings ‐ The study reveals how handoffs can lead to medication errors (by passing information that is not complete, accurate, timely or valid) and can help reduce errors (by preventing, detecting and correcting information quality flaws or prior clinical mistakes). Research limitations/implications ‐ The paper reports on one case study on one hospital unit. Future studies can investigate the impact of clinical IQ on patient safety across the multitude of health information technologies (e.g. computerized provider order entry (CPOE), electronic medication administration records (EMAR), and barcode medication administration systems (BCMA)) and approaches to process design and support (e.g. use of clinical pathways and checklists). Practical implications ‐ The findings can contribute to more successful design, implementation and evaluation of medication administration and other clinical processes, ultimately improving patient safety. Originality/value ‐ The paper's main contribution is the use of accounting control theory to systematically focus on IQ to evaluate and improve end-to-end medical administration processes.
    Full-text · Article · Apr 2013 · Business Process Management Journal
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