Nursing Shift Handover

Standard Operating Procedure: Clinical Nursing Shift Handover

Document ID: TR-OPS-NUR-042
Effective Date: 2023-10-27
Version: 2.1.0
Review Cadence: Biannual (Every 6 Months)
Target Audience: Registered Nurses (RN), Licensed Practical Nurses (LPN), Charge Nurses, Nursing Assistants.

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1. Executive Summary & Scope

This SOP dictates the standardized communication protocol for the transfer of accountability and responsibility for patient care between outgoing and incoming nursing staff. The objective is to mitigate the risk of adverse events, diagnostic errors, and medication mismanagement caused by information fragmentation. This protocol adheres to The Joint Commission (TJC) National Patient Safety Goals and utilizes the I-PASS (Illness Severity, Patient Summary, Action List, Situation Awareness/Contingency Plan, Synthesis by Receiver) framework.

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2. Prerequisites & Tool Requirements

• Documentation Access: Full credentials for the Electronic Health Record (EHR) system.
• Communication Tools: Secured Voalte/mobile device or pager; access to bedside patient monitor interface.
• Safety PPE: Standard Precautions as defined by hospital infection control policy (e.g., isolation-specific gowning if applicable).
• Knowledge Base: Up-to-date patient acuity assessment and current MAR (Medication Administration Record).

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3. Roles & Responsibilities (RACI Matrix)

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4. Step-by-Step Operational Procedure

Phase I: Preparation (15 Minutes Pre-Shift)

• Review current EHR notes, laboratory results, and imaging reports.
• Verify MAR for pending tasks or medication timing.
• Prepare the "Handover Sheet" with critical patient data.

Phase II: Structured Bedside Handover (I-PASS)

• Illness Severity: State clinical status (e.g., Stable, Unstable, Guarded) and reason for current level.
• Patient Summary: Review events of the last 12 hours, procedures performed, and significant diagnostic findings.
• Action List: Identify pending tasks (e.g., upcoming labs, dressing changes, pending transport).
• Situation Awareness: Discuss specific "What-if" scenarios (e.g., "If patient oxygen saturation drops below 88%, implement X protocol").
• Synthesis by Receiver: Incoming nurse summarizes core clinical priorities to ensure comprehension.

Phase III: Post-Handoff Verification

• Perform a joint "Safety Check" of IV lines, tubing, infusion pumps, and patient identification bands.
• Visually confirm patient status and environment safety.
• Document the successful transfer of care in the EHR.

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5. Quality Assurance & Verification Criteria

Audit Frequency: Weekly spot checks by unit charge nurse.
Tolerance: Zero tolerance for missing medication administration data.

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6. Practical Troubleshooting Scenarios

Scenario A: Discrepancy in Medication Count/Administration

• Observation: Incoming nurse identifies a missing dose or potential narcotic discrepancy.
• Corrective Action: Immediate pause of handover. Notify Charge Nurse. Both nurses must perform a manual count and reconcile the MAR against the Pyxis/medication drawer before the outgoing nurse leaves the unit.

Scenario B: Uncooperative or Intoxicated Incoming Personnel

• Observation: Incoming nurse demonstrates impaired cognitive function or refusal to verify clinical facts.
• Corrective Action: Terminate handover. Escort incoming staff to the Charge Nurse or Nursing Supervisor immediately. The outgoing nurse remains with the patient(s) until a secondary qualified nurse is assigned to complete the transfer.

Scenario C: Emergency Admission Interrupting Handover

• Observation: Code Blue or rapid response required during the middle of the handover.
• Corrective Action: Cease non-emergent handover. Outgoing nurse supports the crisis. Once stabilized, the transfer of care is deferred until the clinical environment is secured. Documentation must reflect the time delay.

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Julian Vance
Chief Operations Architect | Template Registry