Translational Research for Practice and Populations
Western Governors University
April 16, 2016
A. Nursing Practice
Shift handoff is probably one of the most difficult times a nurse will face during their twelve hour shift. Our current practice of shift handoff occurs at the nurse’s station roughly around 7am and 7pm. Nurses sit together in pairs and review information about the patients’ current state, past medical history, any test or exams and review all pertinent lab results. Interruptions occur frequently due to phone calls, call lights and residents and fellows requesting updates on their patients and can cause nurses to misunderstand or not hear all the information being exchanged. These misses can ultimately cause harm to the patients.
A prime example of this occurred recently on the unit I work on. A critically ill patient on a mechanical ventilator was receiving fentanyl continuously via his central line for pain control, this being a high risk drug two nurses are required to verify the amount and rate at shift change. On this particular day the unit was busy, many visitors, new nurses and fresh residents walked the hallways seeking assistance. The seasoned nurses sat at the station and discussed their patient and his plan for the day. Trusting each other and having a physician call one of them away, the other just simply signed off on the fentanyl drip without actually verifying its contents. After the morning passed and things began to slow down the nurse and I were in the room to replace the now empty fentanyl syringe. Upon opening up the PCA pump we discovered the syringe was not fentanyl, but in fact was dilaudid. This was a major medication error. Being a clinician within the unit, I had to complete a root cause analysis of this error. After further investigation several faults were discovered in our practice and our safety checks. If bedside shift report was practiced...