Original ArticleSafe and effective nursing shift handover with NURSEPASS: An interrupted time series
Section snippets
Background
Communication failures threaten patient safety, especially at moments when care is handed over from one healthcare professional to another. In an analysis of sentinel events The Joint Commission identified communication and handover failures as a contributing cause in two out of every three sentinel events (The Joint Commission, 2014). In the report, ‘Crossing the Quality Chasm’ the Institute of Medicine stated that handovers provide an opportunity for error and that “in a safe system,
Setting
The study was conducted at the Academic Medical Center, a large tertiary care university hospital in Amsterdam. At the start of our project no formal hospital-wide handover policy existed, neither for nursing or physician shift handover nor for other handover moments. From interviews with senior nurses of different departments we found a large practice variation in handover styles, however reading the nursing files by the incoming nurses and requesting clarification from the leaving nurse if
Results
The three pre-intervention measurement weeks were in March–April 2015, the two week implementation period took place in April 2015 and the three post intervention measurement weeks were in May–June 2015. In total we included 1175 shift handovers in the study (n = 561 pre-intervention, n = 614 post intervention). In the three pre-intervention measurement weeks the nurses evaluated respectively, 185, 198 and 178 handovers in the three post intervention measurement weeks they evaluated 203, 205 and
Discussion
In this pilot study we implemented a handover blueprint with bedside-safety-check on two nursing departments of an academic hospital to determine the effect size on quality of handover. After implementation we observed a continued trend of improvement in handover quality. In the categories organization/efficiency and contents of the handover we saw a significant decrease of low scores. Since these were two topics that were specifically targeted by the handover blueprint, this may explain the
Authors' contributions
HV, study design and supervision; JM, SD, statistical guidance; CD, DA, data collection and implementation; MS, analyses of data; HV, MS, JM; data interpretation; MS drafting the manuscript; all authors, revising the manuscript for intellectual content and final approval.
Competing interest
The authors declare that they have no competing interests.
Funding
No funding.
Acknowledgements
We thank PV for assisting in translating the CEX instrument. We thank head nurses MH and GV for participating with their departments and their leadership support for the project. We thank the senior nurses ER, LB and JG for their help with the implementation and evaluation of the handover blueprint. We gratefully thank all nurses for participating and filling out the 1175 evaluation forms.
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The authors declare that there was no funding and no competing interests.