How can handover communication and documentation be improved to prevent missed inhaler doses and hypoxia in asthmatic patients during shift changes?

Preventing Handover-Related Medication Errors in Asthmatic Patients

To prevent future incidents of missed inhaler doses and hypoxia during shift changes, implement formalized handovers using standardized checklists that include both verbal and written communication, with mandatory documentation of all critical parameters including medication doses and oxygen saturation levels. 1

Implement Structured Handover Protocols

Handovers must be formalized with standardized checklists, similar to aviation pre-flight protocols, as failures of communication during handovers remain among the most common factors contributing to adverse events. 1 The evidence from intensive care settings demonstrates that 50% of critical incidents can be detected by routine checks using structured handover systems. 1

Essential Components of the Handover Checklist

The handover documentation must include:

• All current medications with specific doses and timing (the inhaler dose that was omitted in this case must be explicitly written) 2, 3
• Oxygen saturation measurements and target ranges (the missing O2 saturation documentation directly contributed to this adverse event) 1, 4
• Respiratory rate, work of breathing, and any signs of respiratory distress 4
• Peak expiratory flow measurements if available for asthmatic patients 4
• Patient-specific action plans for deterioration 1, 4

Combine Verbal and Written Communication

Both verbal face-to-face handover AND complete written documentation are required—neither alone is sufficient. 1, 3 The evidence shows that transfer relying solely on written handover without verbal communication increases risk of information loss, while verbal-only handovers lead to omissions like the one described in this case. 1

Bedside Handover Process

• Conduct handovers at the patient's bedside whenever possible to allow visual assessment and verification of equipment, medications, and patient status 2, 3
• The oncoming nurse must actively verify all critical information including medication administration times and oxygen delivery devices 2, 5
• Use a standardized handover tool or template that ensures all essential elements are covered—studies show this improves completeness from 0% to 21% and reduces medication errors by 72% 2

Establish Visual Cues and Documentation Systems

Place prominent visual alerts at the bedside for high-risk patients requiring specific interventions. 1 For asthmatic patients, this should include:

• Bedside signage indicating asthma diagnosis and current treatment regimen 1
• Written asthma action plan visible at bedside detailing when to escalate treatment 4
• Oxygen saturation target ranges clearly documented (typically 94-98% for most patients, or 88-92% for those at risk of hypercapnic failure) 1

Monitor Critical Parameters at Every Shift

Registered nurses must sign medication charts at every drug round and verify that prescribed treatments are being administered, including inhaled medications. 1 This systematic check would have identified the missed inhaler dose before the patient deteriorated.

Specific Monitoring Requirements

• Check oxygen saturation for at least 5 minutes after any change in oxygen therapy or respiratory status 1
• Document oxygen saturation on observation charts at each nursing round, using standardized codes (e.g., "A" for room air) 1
• For asthmatic patients, verify inhaler administration and document response 4

Address Common Pitfalls

The most critical failure in this case was the absence of written documentation of essential treatment parameters. 1 To prevent recurrence:

• Never rely on memory or assumption that the next shift "knows" the routine—all treatments must be explicitly documented 2, 3
• Ensure adequate staffing during handover periods so nurses have protected time for thorough communication without competing demands 2
• Avoid interruptions during critical handover communication about high-risk patients, though allow clarifying questions from the receiving nurse 5
• Implement a "read-back" verification system where the receiving nurse confirms understanding of critical information including medication doses 3

Organizational Requirements

Hospital systems must support effective handovers through adequate human resource coverage during shift changes so nurses are not rushed. 2 The evidence shows that 70% of sentinel events are caused by communication breakdowns, making this a systems-level priority, not just individual nurse responsibility. 3

• Provide standardized handover templates or electronic systems that prompt documentation of all essential elements 2, 6
• Train all staff on the handover protocol including what constitutes mandatory documentation 2, 7
• Audit handover compliance regularly and provide feedback to improve adherence 7