Implementation of Bedside Shift Change Handoff on a Cardiac-Surgical Intensive Care Unit

Abstract

Problem: Medication errors are a significant cause of patient morbidity and mortality, often resulting in serious injuries, prolonged length of stays, and incurred medical costs. In 2019, a Cardiac Surgical Intensive Care Unit (CSICU) at a large academic hospital identified 40 medication errors through a hospital incident reporting system. Reviews of error reports identified that 70% (n=28) involved medications administered through intravenous infusion pumps and estimated that one third could have been detected much earlier if a standardized shift handoff method such as bedside shift-change handoff (BSCH) had been in place. Purpose: The purpose of this quality improvement (QI) project was to implement BSCH with the guidance of a BSCH tool on a CSICU to reduce pump related medication errors. Methods: This QI project took place from August 30 until December 12, 2021. The initial BSCH process incorporated nursing handoff start to finish inside patient rooms; however, observational audits identified inconsistent participation and barriers to this process. At the halfway point of implementation, a rapid cycle Plan Do Study Act (PDSA) change was required to address barriers to implementation. This change allowed nurses to enter rooms at the end of handoff and perform aspects on the BSCH tool, which improved nursing adherence to the practice change. Chart and observation audits collected throughout implementation identified trends in BSCH adherence and duo verification of high alert infusions. Results: One hundred percent of nursing staff (n=103) were educated on the initial process change of BSCH as well as the rapid cycle PDSA change (n=88). Staff adherence to BSCH ranged from 20-51% during the initial phase of the project, and then improved during the second half, ranging from 80-96%. Adherence to duo verification of high-alert infusions doubled, increasing from 41-49% to a range of 82-96% during the last four weeks. Pump related medication errors decreased by 75% (n=2) from the first quarter of 2021 (n=8) and staff identified 13 potential errors, or “good catches”, during BSCH. Conclusion: Implementing BSCH results in many good catches, improving safety and preventing patient harm. Findings support the implementation of BSCH to decrease pump related medication errors