Safe Patient Care Case Study

A Case Study6

Nurse caring for a patient at a disadvantage by not having information that may be necessary to make critical decisions for safe patient care. Patterson et al (2004) examined hand off in settings with high consequences for failure, such as, NASA, the Johnson Space Center in Texas, Nuclear Power generation plants in Canada, a railroad dispatch center in the United States and an ambulance dispatch center in Toronto. Patterson found that hand offs in these settings were interactive, verbal, face-to-face interactions between incoming and outgoing personnel. This allowed for questioning and checking for accuracy of information. Validation of information was found to be an important factor in maintaining the plan for care or daily

Likewise in healthcare, oncoming staff generally does initiate not patient care delivery until a hand off process occurs. “Communication failures are increasingly being implicated as important latent factors influencing patient safety in hospitals.”(Sutcliffe, 2004, p. 187) Parker (1996) reports, “the nurses handing over had direct knowledge of the patient and were able to convey idiosyncratic and personal knowledge of the patient. This is a crucial element in professional nursing practice. The nurse can report on clinical judgments and can be held accountable for the judgments made” (Parker, 1996, p. 25) Critical evaluation of nursing actions can be evaluated and considered to be either continued or discontinued based on the rationales for the action and the patient outcome. In 2005, the Australian Council for Safety and Quality in Healthcare published a literature review of clinical handover and patient safety. This report was compiled in an effort to appraise the evidence available and the research completed regarding nursing handover. Healthcare hand off processes, tools and guidelines for hand off were examined (Safety Council, 2005) the council identified three major domain areas related to

However, in smaller, regional hospitals, it may be more likely that patients are known to each other. The extent to which bedside handover is appropriate in these situations remains unknown. A previous survey showed that almost 30% of 74 patients perceived the presence of other patients in the room during bedside handover as somewhat disturbing.30 it appears that nurses need to carefully consider how sensitive information is shared during bedside handover. Nurses perceived bedside handover in a positive light, believing it improved the accuracy of the information they handed over, however no comparison was done with other handover types, so this perception may not be accurate. Our participants said that patients’ presence not only prompted outgoing nurses to remember information that should be passed on, it also prompted oncoming nurses to ask questions and seek clarification, which may account for the perceived accuracy of bedside handover. In conclusion, this case study of bedside handover used by nursing staff in six wards in two hospitals provides a description of its structures, processes and perceived outcomes. This information may be used as the basis for standard operating protocols for more widespread implementation. Importantly, to date, measurable benefits of bedside handover for nurses and patients are yet to be firmly