Consult a Texas Nurse Attorney discusses Hand-off Reports: Shepherding a Safe Transition of Care
As a nurse on the unit, you were getting to end your shift. You gave report to the incoming nurse, drove home, and took a long nap. Your cellphone phone rang and it was your colleague calling you whether the unlabeled specimen found at the bedside table belongs to your patient that was supposed to be sent to the lab for blood culture prior to receiving a dose of antibiotic that was found to have never been infused because the tubing was clamped. What would you do? The Texas Nurse Attorney discusses:
Shift changes are chaotic most of the time. Everyone just seem to arrive at the nursing station at the same time – providers giving orders, transporters wheeling patients out for first case OR procedure, alarm sounds heard all over the place, phones ringing and the list goes on. You were exhausted after taking care of your high-acuity patients so you tried your best to give the most accurate report, but a very brief one, with no opportunity for questions. The incoming nurse however, tried to make sense of the fragmented report you gave, with the same accountability that you have for safe, effective, and efficient care to the patient.
Problems with handoff communication are listed as one of the root causes in up to 70% of adverse sentinel events compiled by the Joint Commission. Vital information omitted during hand-offs can impact patient’s lives. It is also a leading driver of healthcare malpractice lawsuits but there are ways to error-proof your hand-off report.
Limit interruptions. Be in a quiet location in protected time. If your free parking is going to expire by 8am, notify your colleagues ahead of time.
Mention critical facts first in patient overview. If your patient has a critically low potassium level and replacement is made by pharmacy as you speak, remind your colleague to check the tube station.
Allow for opportunities to ask questions. Use critical thinking skills. Ask why your post-surgery patient has not been started with VTE prophylaxis.
Check for patient safety concerns. Is the patient high risk for a fall episode? If yes, what are the resources available to prevent it?
Standardize. You can create a checklist or a mnemonic that would work in a standardized fashion starting with your unit. If it works, you can bring it up to leadership for hospital-wide adoption.
There is ultimately someone who will be found liable for adverse events due to incomplete, disintegrated, and inefficient hand-offs and it may be up for a jury to decide years after the event. Regardless of the degree of accountability, plaintiff’s attorneys may sue everyone involved in the patient’s care. Therefore, error-proofing your hand-off reports is one way to protect your license and your nursing practice.
Consult a Texas Nurse Attorney Today
If you are a nurse in Texas who is having to deal with the BON due to your hand-off report, it is advisable to consult with an experienced Texas nurse attorney today who can assist you. Contact the Law Office of Yong J. An today at (832) 428-5679 and call or text 24/7.