Miscommunication is the most common cause of medical errors and untoward events. How do we cut through and improve the multiple ways in which communication can be impaired? One way is for nurses to perform change of shift report in a hospital at the patient’s bedside.

Recently I taught a 5 hour preconference legal workshop at the annual meeting of the Academy of Medical Surgical Nurses. One of the poster sessions caught my eye. Staff of Sutter Roseville Medical Center in Roseville, California, embarked on bedside report as a way of improving patient satisfaction. They used a Plan Do Study Act method to implement the change. Some of the key points that helped to drive the change were:

Plan: Identified best practices through interviews and literature searches, created a standardized handoff report, and defined accountability and measures for success including audits and integration into performance evaluation.

Do: Distributed an education module. On the go-live day, supplied new kardexes and handoff report forms.

Study: Placed flip charts in staff lunges for feedback, did spot audits on the handoff report forms, and monitored patient satisfaction scores weekly.

Act: Refined roles of other staff members, such as nursing assistants, shift coordinators and float RNs.

The bedside report system had benefits for both patients and staff.

Patients felt reassured that the staff worked together as a team. This reduces patient anxiety. Patients had a shorter wait for attention during change of shift and used their call lights less often during that time. Patients and families were more involved in care, and the risk of injury at change of shift went down. Patient satisfaction scores rose.

Nurses also obtained benefits from this system. It helped them immediately prioritize the patient’s needs, because all patients were seen. It promoted accountability between shifts – no blaming the other shift for work not done. It provided an opportunity for teaching and mentoring through demonstration equipment, performing assessments, and sharing information related to specific patient needs. It assisted the nurse to be better prepared to answer questions from physicians shortly after change of shift because the nurse saw each patient earlier in the shift.

Bedside repor sounds like a terrific way to reduce medical errors, and is increasingly being implemented by other hospitals.