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Nurse-to-Nurse Change of Shift Hand-Off – Inpatient (Adult & Pediatric) (14.33AP)

Nurse-to-Nurse Change of Shift Hand-Off – Inpatient (Adult & Pediatric) (14.33AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Unit Operations

14.33AP



NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
October 27, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 14.33AP

Original
Revision

Page
1
of 2

Title: Nurse-to-Nurse Change of Shift Hand-
Off – Inpatient (Adult & Pediatric)

I. PURPOSE

To provide guidance and direction for patient safety through accurate, efficient, and
patient and family-centered care communication between registered nurses (RN) at
change of shift.

II. DEFINITIONS (according to UW Health Clinical Policy 3.3.1, Hand-Off
Communication)

A. Hand-off: A transfer of responsibility from one clinician to another clinician.
B. Hand-off communications: An interactive communication allowing the
opportunity for questioning between the giver and receiver of patient information
including up-to-date information regarding the patient's care, treatment and
services, condition and any recent or anticipated changes.
C. SBAR (Situation, Background, Assessment and Recommendation) is a framework
for communication between members of the health care team about a patient's
condition. It is a useful tool for framing any conversation, including critical ones
that need a clinician's immediate attention, and it can be adapted to work in many
situations. (Refer to Related Reference, Use of the “SBAR Verbal Report Guide
for examples of clinical information pertinent to each component of the SBAR
framework.)

III. POLICY

Nurses will conduct a bedside hand-off report at change of shift. This verbal report
will include the patient and/or family (unless barriers, such as patient refusal, cannot
be overcome) and includes a bedside safety check. Documentation is required to
capture the nurse’s shift summary.

IV. PROCEDURE

A. The exact sequencing of the hand-off process will vary according to unit
procedures and patient care needs.
B. Interruptions during hand-offs should be limited.
C. The nursing shift summary documentation in the clinical medical record should
guide and supplement verbal report. This verbal report should follow the SBAR
framework as described in UW Health Clinical Policy 3.3.1, Hand-Off
Communication. It should be concise, limited to clinically significant information,

Page 2 of 2

and include an introduction of the on-coming nurse to the patient and family when
possible.
D. The bedside safety check consists of a brief assessment focusing on the following
components:
1. Quick visual scan of patient (to verify condition appears unchanged)
2. Vital signs and other assessment parameters (if displayed visually on a
monitor), including alarm(s) status
3. Oxygen device status
4. Pain status
5. Vascular access device sites
6. Line reconciliation of IV infusions, other tubes and lines including
appropriate solution and device (if applicable), pump rates, including
high-alert medications, concentration, dose, rate and orders including
patient’s medication administration record (MAR) (refer to UWHC Policy
8.33, High Alert Medication Administration)
7. Safety concerns: Call light, personal items, and bedside table within reach,
safety alarms as appropriate
E. Change the name of the nurse on the communication device (ie; whiteboard).
F. Other issues pertinent to a particular unit.
G. Document shift to shift handoff in the patient’s clinical record
V. UW HEALTH CROSS REFERENCES

A. UWHC Policy 8.33, High Alert Medication Administration
B. UW Health Clinical Policy 3.3.1, Hand-Off Communication
C. Related Reference, Use of the “SBAR Verbal Report Guide”

VI. REVIEWED BY
Director, Nursing Quality & Safety
CNS, Nursing Quality & Safety
Nursing Practice Council, April 2017
Nursing Patient Care Policy and Procedure Committee, October 2017

SIGNED BY

Beth Houlahan DNP, RN, CENP
Senior Vice President, Chief Nurse Executive