Moyale hospital
Shift Handover Protocol
January 2025 EFY
CG&QI
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Purpose
The purpose of this procedure is to have a standardised clinical handover
process in place to facilitate timely, relevant and structured transfer of
information regarding a patients care between health care clinicians to enhance
the continuity of care and optimise patient safety.
Scope
Handover of patient care is a core task for all members of the healthcare team
but will particularly apply to those with a direct role in patient care where they
need to hand over to another team or team member in an effective and efficient
manner.
This policy specifically applies to the handover between shifts in relation to the
immediate care of patients. It applies to all situations where clinical care is
transferred from one healthcare professional to another while the patient remains
in the same care environment. This policy applies to all staff providing care and
who must transfer their responsibilities at the end of a shift.
This policy should be read in conjunction with the Transfer of Patients policy
and Nurse end of shift meeting protocols which applies to the situation where a
patient moves from one area or ward or department providing care to another.
Shift Handover General Procedures
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Patient Handover procedures shall be implemented for daily shift
handover of patients by incoming and outgoing assigned health
professionals and supportive staff;
In addition to clinical Handover all Medicine and materials handover shall
be made at each teams as per the approved formats for this handover
procedures;
Patient information must be updated each shift on the handover sheet by
the assigned nurse. Client information must be updated each shift on the
client’s health record by the assigned nurse. Besides all nursing process
formats shall be updated before commencement of shifts;
An overall brief 10-minute verbal handover is given at the
commencement of a shift by Team leaders and Head Nurses for incoming
shift health professionals;
A team bedside handover, including review of documentation shall take
place after the brief overall verbal handover.
A verbal handover is given at the commencement of a shift by Team
leaders and Head Nurses for the assigned shift professionals;
Oncoming staff shall ensure that they are introduced to, or have an
opportunity to sight, client’s unknown to them.
Any informal handover notes must be placed in the medical record at the
end of the shift.
Daily shift report shall be written by outgoing health professionals and
submitted to Coordinators and Matron;
Daily end of shift report findings should be reported on morning meeting
sessions;
All staff shall appear on time and leave after materials and patient
handovers process has fully finalized;
SBAR communication approach shall be used for clinical Handovers.
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Roles and Responsibilities
Clinical Directors/ Heads of Department
Ensures that this shift protocol is fully implemented by their respective
staff;
Responsible for ensuring there is a process for handover of patients at
each change of junior and senior doctor period of responsibility.
Orient staff on this shift handover protocols;
Take corrective actions when gaps happened on the implementation of
this protocol;
Matrons and Head Nurses
Ensure that all Nurses/Midwives has fully implemented this guideline
properly;
Collect daily shift report and submit summary of the findings once
monthly to SMT;
Responsible for ensuring there is a process in place for nurse handover
and that the process is followed at every shift change.
Orient Nurses/Midwives staff on this shift handover protocols;
Take corrective actions when gaps happened on the implementation of
this protocol;
All Staff
All staff are responsible for Complying with this policy by ensuring they
actively participate in the clinical handover process;
Submit Daily end of shift report to concerned bodies i.e. Matron and team
Leaders;
Completing an adverse incident reporting form in accordance with
Moyale hospital Incident Reporting Policy for any error or omission that
occurs relating to clinical handover.
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Implementation
Clinical Handover processes shall be included during orientation of all new
clinical staff;
Techniques and tools for Clinical Handover are included in staff induction
training manuals.
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