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Leadership Experience C493 Task 1 Western Governors University A1. Problem or Issue The problem I have identified in my work setting is nurse to nurse handoff in the surgery department. Often times, a circulating nurse will retrieve a patient from day surgery and there will not be any report given. The operating nurse then takes the patient to the operating room where the CRNA will be waiting and surgery takes place. After surgery, the circulator will transport the patient to the recovery room and provide what report they can. The recovery room nurses often have questions that the circulating nurse or CRNA do not know the answer to but would if a nurse report would have been given in day surgery. There are also some circulating nurses who don’t give report to recovery room nurses which leaves a lot of unanswered questions and a risk for patient safety. I would like to develop a standardized report sheet that will be in the patient’s chart and have the patient’s pre-surgical checklist, pre-surgical questionnaire, history, medications received, and a miscellaneous section for other important details. This sheet would also have a section for the CRNA providing anesthesia care to fill out to pass on to the recovery room nurse. The report sheet would prompt a nurse to nurse handoff which would be made mandatory. Nurse to nurse report can prevent adverse events from happening in the OR and recovery room and is a very important part of patient safety. A1A. Explanation of Problem or Issue As I stated above, often times there is no nurse to nurse report when receiving a patient into the operating room and when they arrive to the recovery room. Prior to surgery, the admitting nurses in day surgery are screening patients for surgery. The day surgery nurses are also in charge of making sure a consent is signed and that the surgeon has talked to the patient. Once the consent has been confirmed and the surgeon has seen the patient, the day surgery nurse will medicate the patient with anti-emetics as well as midazolam. It is important for the operating nurse and CRNA, who provides the anesthesia, to know which medications the patient received
and if there are any concerns regarding surgery. There have also been instances where a circulating nurse has picked up a patient and headed to the surgery room only to find out that the patient check in process was not yet complete. If there is a mandatory nurse to nurse report prior to the patient leaving the day surgery department, these errors would not happen. When a patient is dropped off in the recovery room following the completion of their surgery, the operating nurse should provide report on what surgery was performed, incisions sites, and any other pertinent information. The CRNA is responsible for providing a report on what type of anesthesia was performed and any medications givens. This process is not always consistent and needs to be for patient safety. A2. Investigation I discussed this issue with the management team who stated that there have recently been many complaints made by both the day surgery team and recovery room team on the lack of report received or given. After discussing with management, I decided to poll a few co-workers from each area in the surgery department. Out of the 5 nurses I talked to in the day surgery or pre-operative area, only 1 nurse states that she consistently gives report to the receiving RN and another nurse stated that he has never given any sort of report to the nurse receiving the patient. The other 3 RN’s stated that it depends on who the circulating nurse is and whether or not they are busy admitting another patient. When talking to 5 circulating nurses, I had very similar responses from the circulating nurses. One nurse stated that she never leaves the day surgery department without talking to the pre-operative nurse, another nurse said she usually never gets report, and the other 3 nurses also stated that it depends on who the nurse is and if they are currently busy at that time. Next I spoke to nurses in the recovery room. This seems to be where the biggest problem with report is. When talking to 5 recovery room nurses, each nurse stated that they rarely receive a complete report on the patient. These nurses voiced that they either receive a good report from the circulating nurse but nothing from the CRNA or vice versa. The last department I talked to was the anesthesia department. I talked to 5 CRNA’s. Two of the CRNA’s stated that they fill out their sheet of paper regarding patient history and hand it to the recovery room nurse then leave, 2 others stated that they don’t fill out an anesthesia sheet but instead provide a verbal report, and the last CRNA stated that he provides both a written and verbal report.
surgical checklist consists of vital signs complete, consent complete, H&P complete, patient marked by surgeon, orders complete (including preoperative labs), and that nurse to nurse report was completed. This paper would go into the OR where it is given to the CRNA for them to fill out their part of the report. This would include type of anesthesia and any medications given during surgery. The CRNA would then give this paper to the recovery room nurse where she would receive report from both the circulating nurse and CRNA. The nurse to nurse handoff as well as the CRNA to nurse handoff would become mandatory in the department for patient safety. Management would need to stand firm by this and have repercussions or consequences for this who do not want to follow the new policy. A4A. Justification of Proposed Solution or Innovation Based on my investigation and analysis, a nurse to nurse report is not consistently done and this may lead to injury to the patient or create unsafe environment for the patient. Each member of the team taking care of patients should be knowledgeable and responsible for knowing what is happening with the patient for patient safety. The circulating nurse needs to know the patient’s history and that the surgical checklist is fully complete before arriving to the OR. This could prevent serious safety events such as the wrong patient being taken to surgery, wrong surgery performed, medication given that a patient is allergic to, as well as making sure all preoperative labs are complete. A nurse to nurse handoff would ensure this information is accurate and complete. The CRNA need to know what medications were given preoperatively so that they can safely provide anesthesia without giving the patient a medication they have already had. When arriving to the recovery room, the recovery room nurse needs to know what surgery was performed and what to monitor for. The nurse to nurse handoff should include any incisions, local anesthetic used, any tubes or drains placed, as well as any other specific directions from the surgeon. The CRNA should be providing what type of anesthetic was used, last dose of pain or antiemetic medication, as well as any anesthesia reversal agents. The recovery room nurses reported that they were not receiving a complete report from both the nurse and CRNA, so this would help to solve that problem. A5. Resources and Cost-Benefit Analysis This project would require a standardized report sheet that would be printed to be placed in the chart. Currently, the surgery department has a preoperative packet that is printed for every
patient. This sheet could be included in the packet so that there is not extra work involved for the secretary preparing the charts. The sheet could be placed in the front of the chart for easy access for all members of the team. It would take time to build the sheet which would require input from all departments to create the standardized sheet. It would also take time to inform staff of the change in policy and familiarization with the report sheet. Every morning, our department has a 10 minutes huddle- this information could be shared during that time. The department educator could also be used during the day for any questions or concerns that may arise. Since this information would be shared during work hours, no additional time is required for nursing staff or management to provide education. As far as materials, this would only require paper to be printed on. There could also be extra sheets printed out and placed around the unit for people to see and familiarize themselves with prior to rolling out the project. Paper costs approximately $0.01 a sheet. We have an average of 50 surgical patients a day. This would cost $0.50/day to print these sheets. This would be a change in process for a lot of the staff throughout the surgical department. I would be concerned that there may be some push back from the day surgery nurses and CRNA’s who will have some information they will need to fill out on the sheet. I think it will be important to highlight that these changes are for the safety of our patients. The benefit of performing nurse to nurse and CRNA to nurse handoff is increased patient safety and patient satisfaction. The cost is very minimal for the changes as it would cost approximately $0.50 a day in materials and no added time or hours paid for staff. A6. Timeline By April 1st, I plan to have a committee formed. We will have our first meeting scheduled with stakeholders and create a committee. The committee will have a meeting by April 9th. At this meeting, I will share the proposal and document and have discussion about what things we need to change. The following week, we will meet again and finalize changes. On April 19th, the change would be discussed during the morning meeting on every weekday, as well as sent out in email. April 26th will be the go-live date. Staff will be using the forms and performing nurse to nurse handoff report. A7. Importance of Key Stakeholders or Partners The stakeholders or partners for this policy change includes the OR manager, Anesthesia manager, Day Surgery and PACU manager, surgery nurses, CRNA’s, and department educators, and secretaries. Management is important in that they will be the ones who will enforce the policy change. The day surgery, operating room, and recovery room nurses and CRNA’s are
A8. Implementation This change will be implemented by first notifying staff of a change in policy with an effective date of April 26th. There will be education provided starting the week before implementation during our morning huddle meetings, as this is where all new information is communicated in our departments. The standardized report sheet will be available for staff to preview prior to initiation of the policy change. Once the change goes into effect, management has agreed to make frequent rounds throughout the day to their departments to see how the change is going and to receive any additional feedback. Success will be measured by PACU nurses turning in the standardized report sheets after they are finished with them. This will help us to see how many of the report sheets are being filled out and following the patient through surgical services. A survey will also be sent out to all departments 4 weeks after the change is implemented. For the operating room nurses, the survey will ask: On a scale of 1-5, with 5 being always and 1 being never, how often are you receiving report from a day surgery nurse prior to taking the patient to the operating room? For the recovery room nurses, the survey will ask: One a scale of 1-5, with 5 being always and 1 being never, how often are you receiving report from an operating room nurse? One a scale of 1-5, with 5 being always and 1 being never, how often are you receiving report from a CRNA? B1. Role of Scientist I was a scientist by first noticing that there was a lack of nurse to nurse report and then by investigating how often nurse to nurse report was being performed and the effect it has on the nurse’s knowledge of a patient. I was able to determine that nurse to nurse report was not consistently being done by polling my coworkers and through discussions. I then came up with a proposal for standardized report sheet and mandatory nurse to nurse handoff when a patient moves through the different departments of surgery. B2. Detective I was a detective in the investigation by trying to find the root cause of why nurse to nurse report was not being done. I determined that the root cause is that there has never been a policy and that nurse to nurse report has never been mandatory in the surgery department.
B3. Manager of the healing environment As a manager of the healing environment, I recognize that in order for nurses to care for patients safely, a nurse to nurse handoff should be performed. I was becoming concerned that adverse events might happen if staff isn’t fully aware of a patient’s history or status. I also want to improve teamwork in the surgery department. When nurses from different departments feel like they are working together towards a common goal, moral increases as well as job satisfaction. I feel like this proposal will encourage teamwork and increase communication among coworkers.
