How can medication errors and omissions of vital signs during nurse handovers be prevented in patients with asthma?

Preventing Handover Errors in Pediatric Asthma Patients

To prevent medication dosage and vital sign omissions during nurse handovers, implement a standardized verbal handoff using a structured communication framework (such as I-PASS or ISBAR) combined with an electronic health record-generated written checklist that auto-populates critical patient data. 1, 2, 3

Implement a Structured Verbal Handoff Framework

• Use the I-PASS mnemonic (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) for all verbal handoffs, as this framework has been proven to improve communication quality in pediatric settings without increasing handoff duration. 2

• The I-PASS implementation significantly increases inclusion of critical elements: illness severity assessment (from 37% to 67%), patient summary (81% to 95%), to-do lists (35% to 100%), and opportunities for receiving nurses to ask questions (34% to 73%). 2

• ISBAR (Introduction, Situation, Background, Assessment, Recommendation) is an alternative framework that increases interprofessional communication skills, confidence, and quality of clinical information transfer, resulting in increased patient safety. 1

• Structured handoff tools reduce interruptions during handoff from 67% to 40% of handoffs, which is critical for preventing information loss. 2

Combine Verbal Handoff with Electronic Health Record-Generated Written Tools

• Implement EHR-generated handoff printouts that auto-populate patient data fields, as these reduce transcription errors and improve accuracy from 51% to 97% for critical patient data points. 3

• EHR-generated tools eliminate manually scripted handoff errors, particularly for medication lists, reducing incorrectly listed medications from 51% to 0%. 3

• The written checklist should include all essential patient information specific to asthma management: current medication dosages, vital signs (respiratory rate, heart rate, oxygen saturation, peak expiratory flow), recent nebulizer treatments, steroid administration, and response to treatment. 4, 2

Essential Elements for Asthmatic Patient Handoffs

For pediatric asthma patients specifically, the handoff must include:

• Illness severity assessment: Document if the child has features of acute severe asthma (too breathless to talk/feed, respirations >50/min, pulse >140/min, PEF <50% predicted) or life-threatening features (PEF <33%, silent chest, cyanosis, altered consciousness). 4

• Medication dosages and timing: Exact doses of nebulized bronchodilators (salbutamol 5 mg or terbutaline 10 mg), frequency of administration, ipratropium doses (100 mcg), and corticosteroid doses (prednisolone 1-2 mg/kg or hydrocortisone). 4, 5

• Vital signs and monitoring parameters: Oxygen saturation (maintain >92%), respiratory rate, heart rate, peak expiratory flow measurements before and after treatments, and any arterial blood gas results if obtained. 4, 5

• Response to treatment: Document whether the patient is improving or deteriorating, as this determines escalation of care. 4

Implementation Strategies to Ensure Compliance

• Provide educational training to all nursing staff on the structured handoff framework before implementation, as education is a core component of successful handoff bundles. 2

• Use visual materials and reinforcement tools (posters, pocket cards) to provide ongoing reminders and sustainability of the handoff process. 2

• Ensure face-to-face verbal handoffs occur at the bedside whenever possible, as this allows the receiving nurse to ask clarifying questions and verify understanding. 1, 6

• Build in a "read-back" or synthesis component where the receiving nurse summarizes their understanding of the patient's condition and plan, as this verification step catches omissions before they cause harm. 2

Common Pitfalls to Avoid

• Never rely on verbal handoff alone without written documentation, as information retention from purely verbal communication is poor and prone to errors. 4, 3

• Avoid non-standardized, free-text handoff notes that are manually transcribed, as these have 51% error rates for critical patient data and medication lists. 3

• Do not allow interruptions during handoff, as 67% of handoffs with interruptions are associated with information loss; create a protected handoff environment. 2

• Ensure the handoff includes verification of comprehension, as studies show only 22% of patients/staff are given opportunity to confirm understanding without structured processes. 4

• Recognize that asthmatic children can deteriorate rapidly—the handoff must explicitly state the threshold for escalation (when to call physician, when to increase treatment frequency, when to prepare for ICU transfer). 4, 7, 5