Communication of information between healthcare providers is a fundamental component of patient care.
Reporting mechanisms employed when providers change shifts are an integral component of the communication process used to convey information about patients between healthcare providers. At Hamilton Health Sciences (HHS), prior to the implementation of the TOA project, methods used for transferring patient accountability between care providers differed.
The objectives of the TOA project were to review the handover processes at HHS, develop TOA practice guidelines, provide an appropriate framework through which nurses can handover patient care, implement a standardized approach to TOA and evaluate the effect of the project on patient safety within HHS. Hamilton Health Sciences (HHS) is a 1,000-bed regional tertiary care facility comprising five distinct hospitals and a cancer centre, serving more than 2.2 million residents of Hamilton and Central South and Central West Ontario.
Analysis also revealed that nurses on each unit perceived the usefulness of the written tools differently. The conclusion of the study was that nurses were not comfortable communicating nursing information during face-to-face interaction at the bedside. The results and conclusions were disseminated to the HHS executive team, who decided that further development and implementation was warranted. A mechanism (safety checklist) to review key patient safety issues, identify errors and limit patient harm must be introduced. One person must have a total picture of the unit through the use of a charge nurse written tool.
The TOA workshops were scheduled every two weeks, to allow members time to work with the nurses on the units to develop, review, test and revise their TOA standards, written tools and face-to-face reporting methods.
Plans to extend this project to explore TOA within and between other disciplines and facilities are under way.
The purpose of the TOA project was to provide an evidence-based framework to support nurses' handover of patient care, and to implement a standardized approach to TOA to promote patient safety.
The authors of the paper would like to acknowledge the dedication and commitment of the clinical managers and staff nurses at Hamilton Health Sciences. If you are not frequently holding safety meetings, you are in violation of OSHA’s required meeting law and subject to fines.
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Clipping is a handy way to collect and organize the most important slides from a presentation. We would very much appreciate if you could complete our site survey so that we may gain from your experiences and ensure that our future plans and enhancements target your specific needs. A number of terms are used to describe this exchange of information, such as patient care handover, transfer of accountability, bedside reporting, and shift handover.
Transfer of accountability (TOA) practices vary across and within healthcare organizations. Concerns related to the usefulness of the information and congruence between the report and the patient condition were raised.
The facility employs over 3,400 registered nurses (RNs) and registered practical nurses (RPNs) who are actively involved in communicating patient information between nurses at shift change, and between units and hospitals when transferring patients. The first phase of the project was to determine the current handover practices within the organization. An expert panel of nurses including administrators, educators and clinicians reviewed over 25 relevant research and opinion articles related to patient handover. The guidelines identify and expand upon the three distinct phases of TOA: pre-handover, inter-shift handover and post-handover. Two clinical inpatient units, a 16-bed general medicine unit and a 34-bed obstetrical unit participated in the pilot study. One unit used a generic computer-based form; the nurses on the other unit developed their own form.

Face-to-face reporting needed to be introduced, along with education to enable nurses to use this component. An implementation plan, including guiding principles and a staged implementation, was suggested.
The Advisory was made up of nurse leaders, a patient safety specialist, a clinical educator, a clinical system professional and staff nurses. This process helped to ensure the tools met the needs of the unit while remaining consistent with the guiding principles. A communication book was kept on the clinical units, in which nurses wrote questions and comments as TOA was implemented.
In addition, McMaster University School of Nursing is exploring ways to introduce TOA education into the undergraduate curriculum. Prior to the TOA project, a lack of consistency in practice about appropriate nursing change of shift handover resulted in confusion about the appropriate information to communicate. Nancy Poole, RN, BScN, is an Education and Development Clinician and was the Coordinator for the Transfer of Accountability project, Hamilton Health Sciences, Hamilton, ON. They supported and implemented the Transfer of Accountability initiative to improve communication and safety related to patient care.
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As a result, a team of nurses with expertise in practice, policy and research related to patient care communication was established under the auspices of the HHS Professional Affairs portfolio. In 2002, a survey was conducted, the aim of which was to determine both the handover practices of nurses and the length of time involved at shift change.
Within the pre-handover phase, a review of patient information is obtained from the chart, team members, patient and family; a written report capturing the key pieces of information about the patient is prepared. Nurses chose to modify the written tools to make them more appropriate for the particular unit.
Nurses were more accepting of the TOA guidelines when they were involved in the development or identification of written tools for the staff nurse and charge nurse.
They determined that the introduction of a bedside patient safety checklist, face-to-face dialogue and a written tool for both the charge nurse and the staff nurse would help nurses establish and maintain the principles of TOA. Each workshop opened with storytelling from the members to foster collaboration and mutual problem-solving. One book exemplified the evolution in feelings and beliefs of the nurses as they implemented the practice change. Nurses are reporting improvements in the congruency of information received in handover and their patient assessment. Lack of communication of significant patient information among nurses sometimes led to an inappropriate plan of care and ultimately a negative outcome.
According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO 2003), almost 70% of all sentinel events are caused by breakdown in communication.
Inadequate or incorrect information jeopardizes patient safety and the continuity of care (Anthony and Preuss 2002). Using the best available evidence supporting bedside reporting, and through a process of consensus, TOA guidelines were developed.
The survey was distributed to the clinical educators for each of the 52 inpatient areas; responses for 36 units (69%) were received.
The format of this report, including content, can differ for patient care units, according to the information needs of care providers. Nurses were provided with an information package on each unit, and support was provided through e-mail and telephone contact. Analysis revealed that the form developed by the staff nurses was perceived as much more useful than the generic form (p = 0.00, 2-tailed t-test).
Implementation teams consisting of a manager, an educator and a staff nurse were identified for each area that had shift handovers. The project coordinator followed up with members between meetings, offering to meet with staff and to assist with testing out the new tools and methods. Patients have expressed their satisfaction with the process, particularly the bedside check. The use of TOA guidelines, a relatively standardized approach, can decrease the chance of negative outcomes, because of the limits placed on the variety of methods used to perform a task (Porto 2001).

This was achieved by developing nursing standards for patient safety during transfer of accountability and introducing written tools, a bedside patient safety checklist and face-to-face reporting. Issues and concerns regarding the effectiveness of handover at shift change were raised by nurses throughout Hamilton Health Sciences (HHS), leading to the approval of a hospital-wide project to implement evidenced-based Transfer of Accountability (TOA) Guidelines and a bedside patient safety checklist. When the process for this transfer varies between settings or healthcare providers, the risk of missed or incorrect information is elevated. The guidelines were pilot-tested and subsequently implemented in units with shift handovers across the organization. Analysis of the responses revealed that nine different shift-reporting mechanisms were being used, including combinations of verbal, taped and written methods (see Figure 1). During inter-shift handover, the off-going and the on-coming nurses engage in a verbal report and complete a patient safety checklist at the bedside.
Four months following implementation of the TOA guidelines, a questionnaire was developed and structured to determine the frequency and perceived usefulness of completing each component of handover.
Implementation team members attended the series of five workshops, during which they planned for implementation on their wards, developed a communication plan, drafted TOA standards and drafted written tools for the staff and charge nurses. The teams reconvened three months after the workshops to review progress and to celebrate successes. They are reassured by knowing information about their care requirements has been communicated between nurses.
Use of a structured tool can also stimulate recall for nurses, ensuring that assessment about key issues is conducted and the reporting of significant findings enhanced.
The standardized approach to TOA improves the effectiveness and coordination of communication among nurses at shift change, and fosters complete communication of information related to patient needs during provision of care. This article describes the development of the guidelines, the results of the pilot study and the ongoing implementation of the project.
Length of handover ranged from as little as one or two minutes per patient on a ward to more than six minutes per patient in critical care areas (see Figure 2). Responses were obtained from 57 of the 59 (97%) registered nurses and registered practical nurses working on these units.
Following this, a five-step plan for implementation of TOA was developed to ensure effective engagement of staff and support a sustainable transformation within the organization. Incorrect patient armbands and IV solutions have been identified and rectified during the bedside patient safety check. The next step of this project is to understand and enhance handover practices within and between other care providers and facilities. Ablution blocks, Baths and Toilets Are the ablution and toilet blocks comply with standards and156. Analysis revealed that, overall, nurses were completing the written and verbal handover as per the new TOA guidelines. One nurse stated, "the checking of armbands is good, I had an incident where I was going off nights and checking an armband. The JCICPS goes on to suggest that systems and processes must be established to ensure complete communication of information. At times, they were choosing to conduct the face-to-face component in the hall outside the patient's room.
While each unit implemented the three phases of the TOA process, they modified the inter-shift handover.
The Canadian Patient Safety Institute (CPSI) has recognized the importance of this issue, designating implementation and evaluation of new mechanisms for communication within and between caregivers as a research priority (2006). Nurses excluded the bedside safety checklist, because the process had not yet been clearly defined. 50 liters (or half a days supply, whichever is less) and is it kept in a fire resistant cupboard or bin?

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