HLTH 4110 Week 8 Shift Handoff Analysis Example

What the 0700 Report Carries and What It Drops: A Handoff Analysis of Shift Change on 5 West

Student Name

Walden University

HLTH 4110: Healthcare Quality and Safety

Instructor Name

Month Day, Year

What the 0700 Report Carries and What It Drops: A Handoff Analysis of Shift Change on 5 West

Handoff as a Task

At 0700 on 5 West, twelve night nurses hand over about thirty patients to twelve day nurses in roughly twenty minutes. Information that took twelve hours to gather moves in about two minutes per patient. The event studied earlier this term began with information that made it across this handoff in one form and was lost in another: the outgoing nurse reported the ultrasound fast, and the oncoming nurse noted it, but neither connected it to the mealtime insulin due at 0800. This paper analyzes the 0700 handoff as a structured task, examining what its format carries, what it drops and what interruption does to both. The observations are a composite built for this assignment.

How Handoff Works on 5 West

Report is given at the central station rather than in patients' rooms. The night nurse reads from the unit's paper report sheet, which has printed lines for diagnosis, code status, allergies, intravenous lines, diet, last vital signs, pain and a blank box labeled plan. The day nurse writes on a fresh sheet or on a copy of the night nurse's. Medications are not discussed unless something unusual happened overnight; the expectation is that the day nurse will review them in the electronic record before the first pass. There is no structured place to name medications due before breakfast or the conditions attached to them.

What Was Observed

I observed ten handoffs over three mornings, each for a patient who received insulin. Table 1 summarizes what was said.

Table 1

Content and Interruption in Ten Observed 0700 Handoffs for Patients Receiving Insulin (Composite Observations)

What the Format Carries

The sheet reliably carries the items printed on it. Diagnosis, code status and allergies were mentioned every time, because the night nurse reads down the page. That is the strength of a structured format: it makes certain items hard to forget. Research on handoff tools generally finds that structure improves completeness for the items the structure includes (Patterson & Wears, 2010). The 5 West sheet was designed years ago around what a nurse needs to know in an emergency, and for that purpose it works.

What the Format Drops

The sheet drops whatever it does not print. The insulin plan was mentioned in only three of ten handoffs, and only when something had already gone wrong overnight. Diet status was mentioned in seven of ten but always as a fact about food, never as a fact about medications. The plan box, left blank for free text, was used for the next test or consult rather than the morning's medications. Nothing on the sheet connects diet to insulin, or tests to the medications they affect, so the connection depends on each nurse making it under time pressure. In the event studied earlier, both nurses had the pieces; the format never asked them to put the pieces together.

What Interruption Does

The ten handoffs were interrupted twenty-four times, by phones, call lights and colleagues with questions. After an interruption, the night nurse often resumed one line further down the sheet than where she stopped, skipping an item, and the day nurse sometimes wrote the next item next to the wrong patient. Interruptions do the same damage at the medication pass that follows. In an observational study of hospital nurses, every interruption while nurses were giving medications carried added risk of both procedural and clinical errors, and that risk climbed as interruptions piled up (Westbrook et al., 2010). The station handoff, which sits in the busiest part of the unit at the busiest time, invites exactly that pattern.

What Structured Handoff Programs Show

Structured handoff programs have been tested at scale. When nine pediatric training hospitals adopted one such bundle, which combined a mnemonic, training and a printed handoff document, the change was followed by about a 23% fall in medical errors and a steeper fall in preventable harm, and handoffs did not take longer (Starmer et al., 2014). That study involved physicians rather than nurses and a different patient group, so its results cannot be transferred directly to 5 West. What it does show is that the content and format of a handoff can be redesigned, and that redesign can change outcomes rather than only satisfaction.

Recommendations

The analysis points to three changes. The first is to add a printed line to the report sheet for medications due before the first meal, with a prompt beside it: affected by diet or tests? That turns the connection between diet and insulin from a matter of memory into an item the night nurse reads aloud. The second is to move handoff for patients on insulin to the bedside, where the nurse can see the breakfast situation and the patient can confirm whether they have been told not to eat, and where phones and call lights interrupt less. The third is to protect the first ten minutes of handoff from nonurgent phone calls by routing them to the charge nurse. The unit could test all three on one hallway for two weeks and repeat the observation to see whether the insulin plan is mentioned more often.

Limits

Ten observed handoffs on three mornings is a small sample, and nurses aware of an observer may have covered more than they usually do, which would make the gaps larger in practice. The analysis also does not cover the evening handoff, which precedes the dinner dose and may have different problems.

References

Patterson, E. S., & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. The Joint Commission Journal on Quality and Patient Safety, 36(2), 52-61. https://doi.org/10.1016/S1553-7250(10)36011-9

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., ... Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. https://doi.org/10.1001/archinternmed.2010.65