Reducing Patient Clinical Management Errors Using Structured Content and Electronic Nursing Handover

Quality and Safety in Nursing: Recommendations From a Systematic Review

ABSTRACT

As a consistent 24-hour presence in hospitals, nurses play a pivotal role in ensuring the quality and safety (Q&S) of patient care. However, a comprehensive review of evidence-based recommendations to guide nursing interventions that enhance the Q&S of patient care is lacking. Therefore, the purpose of our systematic review was to create evidence-based recommendations for the Q&S component of a nursing professional practice model for military hospitals. To accomplish this, a triservice military nursing team used Covidence software to conduct a systematic review of the literature across five databases. Two hundred forty-nine articles met inclusion criteria. From these articles, we created 94 recommendations for practice and identified eight focus areas from the literature: (1) communication; (2) adverse events; (3) leadership; (4) patient experience; (5) quality improvement; (6) safety culture/committees; (7) staffing/workload/work environment; and (8) technology/electronic health record. These findings provide suggestions for implementing Q&S practices that could be adapted to many healthcare delivery systems.

Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative

BACKGROUND

Transfer of care, moving hospitalized patients between care areas, is a critical point of vulnerability for healthcare organizations. Patient information handoff is an essential activity occurring frequently in hospital environments. Poor communication has been linked with adverse events and poor patient outcomes. This evidence-based quality project aimed to enhance the handoff process between the Emergency Department (ED) and Pediatric Intensive Care Unit (PICU) by standardizing transfer of care steps. This was accomplished through customizing a reporting tool to contain all the information the receiving department deemed necessary for safe patient care.

METHODS

A customized situation, background, assessment, recommendation (SBAR) form handoff tool was developed for ED to PICU transfers. This SBAR tool included information that PICU nurses identified as critical to transfer of care. Nurse perceptions were surveyed pre- and post-implementation. Patient safety event reports were tracked to evaluate events related to transfer of care before and after the practice change.

FINDINGS

An increased number of PICU nurses agreed the customized handoff tool was complete and organized. Additionally, more nurses agreed that handoff gave all information needed to safely care for critically ill patients transferred from the ED. Lastly, bedside patient checks increased, and patient safety events related to transfer of care decreased.

DISCUSSION

This project demonstrated that implementation of a standardized transfer of care process coupled with a customized handoff tool increased PICU nurse perceptions that handoff was organized, and all information needed to safely care for critically ill patients was conveyed.

APPLICATION TO PRACTICE

Transfer of care processes between the ED and PICU should be standardized. The use of customized tools may improve information exchange between nurses and ensure that all vital patient information is communicated.

Exploring nurses' perceptions of clinical handover in regional health care facilities: A exploratory qualitative study

AIM

This study sought to explore nurses' perceptions of clinical handover in a regional health care facility to better understand the local context and identify the most appropriate clinical handover models.

BACKGROUND

Clinical handover is an essential aspect of clinical care, and yet using accurate spoken and written communication can be neglected in nursing, potentially resulting in patient harm. Although much information is available on clinical handover in metropolitan settings, few studies have examined the regional context.

METHODS

This study was an exploratory qualitative study based at one small regional health care facility located 100 km from a metropolitan Australian centre. The study utilized an Appreciative Inquiry approach to identify how nurses perceive the use of standardized oral and written clinical handover. Focus groups were engaged to explore the perceptions of nurses "handing over" in the smaller regional facility.

RESULTS

Through focus group interviews with Registered and Enrolled Nurses, the data revealed that the cultural context of the ward influenced perceptions of clinical handover and that handover served as a light in the dark for all nursing staff; as an evolving communication tool illuminating patient care needs.

CONCLUSION

This study facilitated understanding of the handover needs of smaller Australian regional hospitals. This study identified gaps in perception about handover practices between junior and senior nurses. New graduate nurses develop confidence in supportive clinical environments. A transition to practice programme would need to address the challenges new graduates face in the regional setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers in regional facilities can champion supportive senior nurses to mentor new graduate nurses and enhance the transition to practice for the new nurse.

Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-Falls, pressure injuries and medication administration errors: An integrative review

The aim of this integrative review was to identify which nursing handover interventions were associated with improved patient outcomes, specifically patients' falls, pressure injuries and medication administration errors, in the hospital setting. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the review. A systematic search of seven electronic databases was conducted, and retrieved articles were assessed by two independent reviewers. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Eight studies met the inclusion criteria. The findings of this review indicate that improvements in handover communication had a clinically important positive effect on patient outcomes. Across the studies, reductions in falls varied from 9.3 to 80%, pressure injuries from 45 to 75%, and medication errors from 11.1 to greater than 50%. This review highlights that the implementation of bedside nursing handover and the adoption of standardized handover tools to improve nursing handover communication reduce patient adverse events, specifically falls, pressure injuries, and medication errors. These findings should be considered by clinicians to inform their clinical handover practice.

Measuring Nurses' Transition to Electronic Handover: Validation of the Perception and Adaptation Readiness of Electronic Handover Systems Scales

The transition from traditional handover methods to electronic handover is extremely stressful to nurses. This psychometric evaluation study tested the validity and reliability of the perception and adaptation readiness of electronic handover system scales for hospital nurses. A total of 253 Taiwanese nurses from a medical center participated in this study from January to March 2018. The perception and adaptation readiness of electronic handover system scales were self-developed, and content validity was tested via content validity index of the scale. Exploratory factor analysis and confirmatory factor analysis were utilized to test construct validity, while reliability was tested by Cronbach's α coefficient. Four factors explained 50.77% of the total variance in the perception of electronic handover system scale. Three factors accounted for 53.43% of the total variance in the adaptation readiness of electronic handover system scale. The confirmatory factor analysis results indicated a three-factor construct for both scales. Cronbach's α coefficients were 0.83 and 0.91 for the perception and adaptation readiness of the electronic handover system scale, respectively. The scales could be used to assess nurses' perceptions and adaptation readiness of electronic handover, while the assessing result serves as a reference for implementing educational and supportive interventions to facilitate adaptation in nurses.

Translating evidence-based nursing clinical handover practice in an acute care setting: A quasi-experimental study

Effective transfer of information during the nursing handover contributes to patient safety. This study aimed to translate the best practice nursing shift handover recommendations in an acute care setting using the Ottawa Model for Research Use and to explore its effect on patient adverse outcomes (falls, pressure injuries, and medication errors). Using a quasi-experimental design, the study was conducted in four internal medicine wards in a major tertiary hospital. A total of 88 nurses and 110 patients participated in 152 handover observations. The findings showed clinically important increases in percentages and odds of nurses' compliance with shift handover recommendations after the intervention. The patient adverse outcomes after the intervention were compared to the corresponding period of previous year. A reduction was observed for all adverse patient outcomes with incident rate ratios of 0.762 (p = 0.027) for falls, 0.624 for pressure injuries (p = 0.010), and 0.782 for medication errors (p = 0.023). Replicating this study's methodology across multiple clinical settings will increase the generalizability of findings and provide further evidence to inform nursing practice and policy.

Handover in Nursing: A Concept Analysis

BACKGROUND AND PURPOSE

The broad use of the term handover to describe any activity involving the transfer of professional responsibility from one person to another has led to an ambiguous understanding. Recently, handover has become a process central to the delivery of high-quality and safe patient care. The aim of this analysis was to clarify the concept of handover within the context of nursing practice.

METHODS

Rodgers's evolutionary approach was used as the analysis method along with some aspects of the dimensional analysis guided by Caron and Bowers, to understand the perspectives of senders and receivers.

RESULTS

The analysis revealed four attributes of handover: transfer of information, interaction for disambiguation, process, and strategy. Handover is defined as a process for transferring responsibility from sender to receiver through communication through the transfer of information, the interaction for disambiguation, and the context-sensitive strategy for accomplishing the continuity and safety of patient care. The salient dimension of handover was process, and the sub-dimensions were transfer of information, interaction for disambiguation, and strategy. From the sender's perspectives, it is the process of transferring information organized by the sender, and from the receiver's perspective, handover is the process establishing care plan through interactive strategy.

IMPLICATIONS FOR PRACTICE

The definition and identified attributes serve as a heuristic for designing strategies and further developing the construct of handover in nursing.

Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project

OBJECTIVES

The objective of this evidence-based quality improvement project was to improve clinical nursing handovers between registered nurses.

INTRODUCTION

Clinical nursing handovers transfer critical information about the patient's care to oncoming shift nurses. Nurses use structured handover tools to handover patient information. In three adult surgical wards of a Singapore tertiary hospital, a lack of consistency was found in the local handover process when shifts changed. These resulted in ineffective handovers and compromised the patient's safety. Thus, evidence-based interventions were needed so that patient handovers and continuity in safe patient care could improve.

METHODS

This project was implemented in three phases from January 2017 to November 2017 at three adult surgical wards of a tertiary hospital, utilizing the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) module. The pre- and post-implementation audits were conducted using JBI PACES audit criteria. An evidence-based four-pronged approach was employed, including adequate human resource coverage during handovers, a structured and standardized handover, visual cues and a teaching video.

RESULTS

The results of the post-implementation audit of nurses performing handovers (n = 33) showed that handovers using standardized documentation improved from 0% to 21.0% (p = 0.005), which was statistically significant. However, handovers of detailed observations of patients improved from 72.7% to 87.9% (p = 0.215) and handovers of relevant history of patients improved slightly from 93.9% to 97.0% (p = 1.000) but was not statistically significant. Medication error incidents related to handovers was reduced by 72% over a six-month period.

CONCLUSION

The multi-modal approach improved the comprehensiveness and completeness of clinical nursing handovers. These strategies had a significant effect on reducing medication errors related to handovers.

Routine Health Information System (RHIS) improvements for strengthened health system management

BACKGROUND

A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management.

OBJECTIVES

To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence).

AUTHORS' CONCLUSIONS

The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

A systematic review on the structured handover interventions between nurses in improving patient safety outcomes

AIM

This review aimed to elucidate the effectiveness of structured handovers in improving patient outcomes in the wards.

BACKGROUND

Studies have reported that the lack of quality handovers is one of the main causes of adverse effects.

EVALUATION

A search over six electronic databases: MEDLINE; CINAHL; Web of Science; EMBASE; Scopus; and CENTRAL via Ovid concluded nine studies and synthesized by two independent reviewers based on the Cochrane Handbook for Systematic Reviews of Interventions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the undertaking of this review and meta-analysis. All studies published up to February 2019 were considered in this review.

KEY ISSUES

This review has demonstrated that structured handovers reduced the incidences of patient complications, medication errors and general adverse events. However, the results were not statistically significant.

CONCLUSION

Current structured handover formats were effective in reducing problematic handovers such as omission of information, inaccurate information and documentation errors.

IMPLICATIONS FOR NURSING MANAGEMENT

Although there is limited high-quality and rigorous research conducted to gain a clearer understanding of the impacts on patient-related outcomes in nursing care, structured handovers remained effective in reducing the number of mistakes in information transfer.

Nurses' Attitudes Toward the Use of an Electronic Health Information System in a Developing Country

The electronic-based documentation system is considered a major transformation in health care in many hospitals worldwide. Successful implementation of the system makes nurses' jobs easier, saves time, and improves the quality of care that is delivered to patients. However, little is known about the adoption of electronic health information systems in developing countries. The purpose of this study was to understand and evaluate nurses' acceptance and attitudes about implementation of an electronic health information system in Palestinian hospitals. A descriptive, cross-sectional study was conducted with 191 nurses in three governmental hospitals in Palestine. A majority of these nurses understood the need for and accepted the computer-based documentation as demonstrated by their scores on the attitude questionnaire. Inclusion of nurses in early phases of planning and implementation is important. Other developing countries can learn from the Palestinian experience with implementation of electronic health records.

Nursing handovers: An integrative review of the different models and processes available

The aim of this study is to explore the different handover models and processes available and their efficacy in improving handover communication within nursing practice. The handover of information is a key nursing responsibility that ensures patient outcomes through continuity of care. This process is widely recognised as an opening for error that may comprise patient safety. This paper is an integrative literature review that employed an inductive exploratory design. A computerised database search was employed including CINAHL, PubMed and Science Direct and a manual citation search with included papers limited to papers published 2005-2016, in English with full text freely available. This included a systematic search strategy, a critical appraisal of the papers utilising the Critical Appraisal Skills Programme, an inductive data extraction and thematic analysis. Sixteen papers were included in this review. The results detailed that there are various handover models in use, yet there is no evidence that any one model displays superior efficacy. The iSoBAR model and its adaptations remain the only model employed across various specialties. More research is warranted to determine if any handover model displays superior efficacy or transferability.

Implementing web-based ping-pong-type e-communication to enhance staff satisfaction, multidisciplinary cooperation, and clinical effectiveness: A SQUIRE-compliant quality-improving study

BACKGROUND

Frequent multidisciplinary communication is essential in conducting daily radiotherapy (RT) practice. However, traditional oral or paper-based communication has limitations. E-communication has been suggested, but its effects are still not well demarcated in the field of radiation oncology.

OBJECTS

In our web-based integrated information platform, we constructed a ping-pong-type e-communication function to transfer specific notations among multidisciplinary RT staffs. The purpose was to test whether applying this e-communication can increase effectiveness of multidisciplinary cooperation when compared with oral or paper-based practice. Staff satisfaction and clinical benefits were also demonstrated.

DESIGN AND SETTING

A real-world quality-improving study was conducted in a large center of radiation oncology.

PARTICIPANTS AND DATASET USED

Before and after applying multidisciplinary e-communication (from 2014 to 2015), clinical RT staffs were surveyed for their user experience and satisfaction (n = 23). For measuring clinical effectiveness, a secondary database of irradiated head and neck cancer patients was re-analyzed for comparing RT toxicities (n = 402).

INTERVENTIONS

Applying ping-pong-type multidisciplinary reflective e-communication was the main intervention.

OUTCOME MEASURES

For measuring staff satisfaction, eight domains were surveyed, such as timeliness, convenience, and completeness. For measuring clinical effectiveness of multidisciplinary cooperation, event rates of severe (i.e., grade 3-4) RT mucositis and dermatitis were recorded.

RESULTS

Overall, when compared with oral communication only, e-communication demonstrated multiple benefits, particularly on notation-review convenience (2.00 ± 1.76 vs 9.19 ± 0.81; P < 0.0001).When compared with paper-based practice, e-communication showed statistically significant benefits on all eight domains, especially on notation-review convenience (5.05 ± 2.11 vs 9.19 ± 0.81; P < 0.0001) and convenience of feedback notation (4.81 ± 1.72 vs 8.76 ± 1.09; P < 0.0001).Moreover, staff satisfaction was gradually increased from oral (3.57 ± 1.94), paper-based (5.57 ± 2.06), to e-communication (8.76 ± 0.70; P < 0.0001). Secondary measurement confirmed these observations.Before and after facilitating multidisciplinary cooperation by using e-communication, severe (i.e., grade 3-4) mucositis and dermatitis were decreased from 21.7% to 10% then to 5.1%.

CONCLUSIONS

Replacing oral or paper-based practice with e-communication is useful in facilitating RT multidisciplinary teamwork. Staff satisfaction and clinical effectiveness can be increased.