Handoffs are a known “trouble spot” when it comes to patient safety. As nurses, we participate in handoffs any time we transfer care to another provider, whether at change of shift, transfer to another floor or unit, or transfer to another facility. Errors that occur during these times can result from a variety of barriers, many of which are human factors, ranging from understaffing and interruptions to fatigue and information or sensory overload. 

The Joint Commission requires a standardized approach to patient handoffs; it is one of the National Patient Safety Goals (2006 National Patient Safety Goal 2E). During her presentation “Effective Handoff Communication: A Key to Patient Safety” at Nursing2013 Symposium, JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS, shared several acronyms that can be used to help guide a well-organized transfer of information and minimize errors and omissions during patient handoffs. 

SBAR + 2 (See also The Art of Giving Report and The impact of SBAR.)
  Introduction
  Situation
  Background
  Assessment
  Recommendation
  Question & Answer

5 P’s Model
  Patient
  Plan
  Purpose
  Problems
  Precautions

PACE
  Patient/Problem
  Assessment/Actions
  Continuing/Changes
  Evaluation

I PASS the BATON
  Introduction
  Patient
  Assessment
  Situation
  Safety Concerns
  the
  Background
  Actions
  Timing
  Ownership
  Next

What is the standard for nursing handoffs where you work?

References:

Cairns, L., Dudjak, L., Hoffman, R., & Lorenz, H. (2013). Utilizing Bedside Shift Report to Improve the Effectiveness of Shift Handoff. Journal of Nursing Administration, 43(3). 

Riesenberg, L., Leisch, J., Cunningham, J. (2010). Nursing Handoffs: A Systematic Review of the Literature. American Journal of Nursing, 110(4). 

Schroeder, S. (2006). PATIENT SAFETY: Picking up the PACE: A new template for shift report. Nursing2006, 36(10).  

Last week, a nurse in Texas was acquitted after a being on trial for reporting a doctor for practicing bad medicine.  Here are some of the details from the case, which came to be known as the “Winkler County nurses” trial:

• Two nurses, Anne Mitchell and Vicki Gale, reported a doctor because they were concerned about his practice being below the standard of care and affecting patient safety. Another concern was his use of “nontherapeutic treatments and prescriptions.”
• The case against Gale was dismissed; however the felony indictment will remain on her record.
• Mitchell faced a third-degree felony charge and up to 10 years in prison for trying to protect her patients.
• Both Mitchell and Gale were fired from their jobs.
• The American Nurses Association (ANA) and Texas Nurses Association (TNA) both demonstrated their supported openly. The TNA created the TNA Legal Defense Fund to “to support the legal rights of these nurses in Winkler County – and the rights of every practicing nurse in Texas to advocate for patients.”
• On February 11, 2010, Anne Mitchell was found not guilty.

You can read more about the details of the case as chronicled by the TNA here. 

“I was just doing my job,” relayed a jubilant Anne Mitchell, in a phone conversation with TNA immediately following the not guilty verdict, “but no one should have to go through this,” she said.  “I would say to every nurse, if you witness bad care, you have a duty to your patient to report it, no matter the personal ramifications.  This whole ordeal was really about patient care.”

My heart goes out to both Mitchell and Gale for all that they have endured over the last months. While the verdict is a success for nurses and patient safety, what damage has been done simply by the fact that such a case was brought to trial? What are your thoughts? Have you ever been in a similar position in which you felt patient safety was being compromised by a colleague? How did you handle it?