Timmerman Julianna, Sitzer Verna, Eusebio Rhea, Reavis Karen, Marder Lynn
Sharp Healthcare, San Diego, CA, USA.
West J Nurs Res. 2021 Jul;43(7):631-639. doi: 10.1177/0193945920972620. Epub 2020 Nov 22.
The aim of this study was to describe characteristics and content of nurses' handover tools used for handover report and congruence of content shift-to-shift. Nurses use handwritten notes to record information despite recommendations for standardizing content of handover to improve patient safety. A descriptive, cross-sectional study was conducted in a non-profit hospital in Southern California where a convenience sample of 105 registered nurses voluntarily submitted their paper handover tools. Twenty-seven types of handover tools were collected. Participants customized handover tools with color, writing implement, emphasis markings, and symbols. Content analysis revealed that most handover tools contained the patient's name, birthdate, account number, room number, medical history, allergies, code status, systems review, vital signs, medications, vascular access, test results, plan of care, and tasks. Safety/risk-related information was rarely present. Handover tools were context-specific and individualized with handwritten information that was incongruent shift-to-shift. Safety/risk-related information was rare.
本研究旨在描述用于交接班报告的护士交班工具的特点和内容,以及各班次之间内容的一致性。尽管有建议要求规范交班内容以提高患者安全,但护士仍使用手写笔记来记录信息。在南加州的一家非营利性医院进行了一项描述性横断面研究,105名注册护士组成的便利样本自愿提交了他们的纸质交班工具。共收集到27种交班工具。参与者用颜色、书写工具、重点标记和符号对交班工具进行了定制。内容分析显示,大多数交班工具包含患者姓名、出生日期、病历号、房间号、病史、过敏史、急救状态、系统检查、生命体征、用药情况、血管通路、检查结果、护理计划和任务。很少有与安全/风险相关的信息。交班工具是针对具体情况的,且因手写信息而个性化,各班次之间不一致。与安全/风险相关的信息很少见。