How Bedside Shift Reporting Can Decrease Medical Errors

Miscommunication during patient handoffs is a leading cause of medical errors. Research suggests that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.

In 2006, the Joint Commission established a National Patient Safety Goal requiring hospitals and healthcare facilities to implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. And in 2017, the Joint Commission highlighted the risks of poor handoffs in a Sentinel Event Alert.

Bedside shift reporting, when healthcare workers exchange information about patients at their bedside, can address this issue and decrease medical errors.

Patients Handoffs are Ripe for Miscommunication

Patient safety depends, in large part, on the seamless and accurate transmission of information. But transmitting information seamlessly and accurately in healthcare environments is incredibly challenging. Multiple caregivers are involved in patient care and because healthcare is an  around-the-clock endeavor, handoffs occur multiple times each day.

During patient handoffs, caregivers must communicate critical information about the patient and clearly transfer responsibility for patient care. But information can easily be misunderstood and distorted in demanding, dynamic healthcare settings. Interruptions, which are all too common and often difficult to avoid, further complicate handoffs.

Without deliberate effort, patient handoffs are more likely to result in miscommunication than clear communication.

Poor Handoffs Pose Serious Risks to Patient Safety 

“The hazard that ‘fumbled handoffs’ pose to patient safety and the delivery of quality health care cannot be ignored,”  according to Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Ineffective handoffs contribute to gaps in patient care and failures of patient safety, including medication errors, wrong-site surgery, and patient deaths. Poor handoffs can also lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital. Sentinel events — events that result in patient death, permanent harm, or severe temporary harm — are also more likely to occur during change-of-shift times, when on- and off-going staff are often conferencing with one another away from patient rooms.

Bedside Shift Reporting Increases Patient Safety & Decreases Medical Errors

As the phrase implies, “bedside shift reporting” typically occurs at the patient’s bedside. Reviewing the patient’s care plan at the bedside is a powerful tool to decrease medical errors. Here’s why:

1. Patient involvement gives patients an opportunity to clarify and correct.

During a traditional shift report (which typically occurs at a nursing station or in a conference room), one nurse may erroneously report inaccurate information. The day nurse may tell the night nurse that Mr. Smith has no known allergies when, in fact, Mr. Smith has a serious penicillin allergy. It’s an easy mistake to make when one is caring for four or more patients — and one that could result in Mr. Smith getting a dose of a medication he’s highly allergic to.

During bedside shift report, Mr. Smith (or a family member) is likely to interject: “Did you say I don’t have any allergies? I’m allergic to penicillin!”

2. Two nurses simultaneously check and verify medications and plan of care.

When two people review medication dosage, routes, and planned treatments together, errors are less likely to occur. If two nurses look at the IV bag and pump setting together, for instance, and one notices that lactated Ringer’s solution is hanging instead of normal saline, the mistake is much more likely to be corrected in a timely manner.

3. Underscores the value of patient and family input.

Patients and family members often feel lost in healthcare settings. All too often, care happens to patients, instead of with them. Bedside shift reporting includes patients and family members as valuable members of the healthcare team.

4. Increases efficiency and decreases task overload.

Several research studies have demonstrated the efficiency of bedside shift reporting compared to traditional shift report. One study found that nursing overtime decreased by 10 minutes per day after the implementation of bedside shift reporting; another study found that average report time decreased from 45 minutes to 29 minutes. Other studies have noted that nurses report improved efficiency and increased ability to prioritize care.

This increased efficiency decreases task overload and overwhelm, which commonly trigger errors. Improved efficiency allows nurses and other healthcare providers to focus and safely provide care.

SwipeSense Nursing Insights allows hospitals and healthcare units to measure and improve bedside shift reports, which can help institutions decrease medical errors and protect patient safety.