Health Leadership and Management Innovation


A patient care facility has the responsibility of delivering health care to patients in a timely, safe and effective manner. However, often, the overcrowded and unpredictable nature of care settings coupled by the fragmentation of care delivery system makes effective care delivery problematic. In particular, medication errors often arise due to “absence of information or incorrect information” (Bomba, & Prakash, 2005, p.68), which can have adverse effects on patient care. The passage of incorrect information results from ineffective communication modes used by practitioners during patient transition or administration of medication. A breakdown in communication especially during the end of shift handoff can have deleterious effects on patient care (National Patient Safety Agency, 2007). Thus, ineffective end-of-shift handoff resulting from either a poor communication modes or failure of medical records systems poses a risk to a hospital, the nursing staff and patient outcomes.

However, a standardized end-of-shift care handoff tool will reduce the risk of medication errors, improve patient safety and increase clinical staff and patient outcomes (Clancy, 2006, p. 416). In view of this, the Martha Hospital (MH), an acute care hospital, has recognized the need for a computerized clinical documentation system (CDS) for the surgical unit (SU) to address the problem of medical errors and promote service delivery. The implementation of a CDS during handoffs will involve Kotter’s model for institutional change to facilitate its adoption as a strategy for improving the patient outcomes and decreasing the risk of medication errors (1999, p. 118). Normally, the risks of medication errors arise due to failure to communicate the essential details of care between practitioners at the end of a shift (Queensland Health, 2007). The use of a standardized handoff tool will result to improved communication of critical elements of care, which will result to increased clinical staff satisfaction and improved patient outcomes in care settings.

Identification of the Need and Aim of the Innovation

The computerized clinical documentation system (CDS) patient care handoff will be a powerful strategy in MH healthcare setting. This mode of communication addresses the patient safety concerns, promotes patient nursing and medical care plans, and facilitates the continuity of care. At MH, the rate medication errors arising from poor communication between care providers at the end of a shift is high. The JCAHO report established that inaccurate or the lack of patient information often poses a risk to patient care (Croteau, 2005, p.11). Of the 2,966 medication errors reported between 1995 and 2004, 65% resulted from a breakdown in communication. Thus, the absence of systems and handover protocols increase medication error incidents and may jeopardize the safety of patient care.

According to Mathias “inadequate handoffs affect the patient care safety provided” (2006, p. 15). Additionally, the absence of a standardized patient care handoff in MH causes unnecessary delays in care and increases the risk of inappropriate treatment. This may lead to lawsuits and increases patient complaints over care delivery (Bomba, & Prakash, 2005, p.71). Therefore, the CDS will aid improve the safety of care interventions and mitigate the causes of adverse events at MH. A study of the medication error incidents by surgeons established that communication breakdowns contribute over 43% of error incidences with two-thirds of these incidences attributed to handoff issues (Bourne, 2000, p.60). Usually, physicians use a sign-out sheet as a common practice for communication. However, a study by Robinson, established that, 67% of the sheets bear errors such as incorrect or incomplete medication information, which result to adverse medical events (2002, p.187).

In addition, in terms of organization, hospital settings are becoming complex and disconnected each day and this intensifies the already existing communication woes in most organizations. One study established that, 23% of physicians had difficulties identifying nurses responsible for a patient at a given shift and this highlights the gaps that “exist in communication among practitioners especially when transferring information about a treatment at the end of a shift” (Horwitz et al., 2007, p.1472).

The Evidence

The handover practices in healthcare settings remain an issue due to high incidences of adverse events. The current handover practices include a combination of checklists or computerized systems within a care setting (DiClemente, & Velasquez, 2002, p. 211). According to Kuperman, the handover tools fail to focus on pertinent patient information essential in meeting the treatment goals (2003, p.35). Ineffective handover often results to wrong treatment, medical misdiagnosis, patient complaints and increased overall healthcare expenditure due to increase in the patient length of stay (New Zealand Resident Doctors’ Association, 2007).

Additionally, the ineffective handover tools are largely the cause of medication errors in care settings. In fact, ineffective handover practices account for 65% of medication errors in care settings (Groah, 2006, p.227). Thus, the development of evidence-based clinical hand-over tool is necessary for effective handover.

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