In the assigned reading for week 2, Core Principles & Values of Effective Team-Based Health Care, the authors describe the handoffs as a peril. The authors go on to state that the handoff from clinician to another clinician are associated with avoidable adverse events and many near miss cases. The article states that lack of purposeful team care can lead to unnecessary waste and cost. Communication is imperative when caring for patients and performing handoffs.
In our facility we had a SRE (serious reportable event) last year. Upon performing an investigation the leadership team were able to ascertain that the nurse who gave hand off stated to the oncoming new grad RN “She’s having a lot of pain issues, so I medicated her and she seems to be in a lot of pain still.” The new RN came in the room and assessed her patient and saw the patient writhing around in the bed moaning. The RN was unable to obtain a blood pressure as the machine kept attempting too but it wouldn’t read. The RN thought it was because she was in pain and moving around. After about 20 minutes of this, the RN walked out of the room to call for anesthesia to come place orders for pain medications. In the time the RN left the room and returned the patient was in cardiac arrest. Upon further investigation, the patient was hemorrhaging internally from a cesarean section. Her pain was caused by the hemorrhage, her lack of blood pressure reading was because she didn’t have a blood pressure, her writhing in the bed was because her SPO2 was low and she was confused. Had hand off been more thorough with better communication, perhaps her hemorrhage would have been caught sooner. There was poor communication in the handoff and the off going nurse portrayed her opinion instead of utilizing the new RN to help evaluate what could be going on. Solid communication and collaboration upon caregivers help to prevent adverse events.
Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C., . . . Von Kohorn, I. (2012). Core Principles & Values of EffectiTeam-Based Health Care. Institute of Medicine. Retrieved July 03, 2017, from https://nam.edu/wp-content/uploads/2015/06/VSRT-Team-Based-Care-Principles-Values.pdf.