Date of Graduation

Fall 12-17-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

First Advisor

Cynthia Huff


Problem: In the pediatric setting, the change-of-shift report does not traditionally happen at the bedside. Medical error is a significant health challenge in the healthcare system, with substantial effects on patient safety, including disability or death. Failure of effective communication during the hand-off process contributes to approximately 30% of all malpractice claims. Furthermore, inadequate hand-offs have been shown to contribute to 1,744 deaths and $1.7 billion in malpractice costs over five years (Joint Commission, 2017).

Context: The microsystem setting for this improvement project is a 32-bed pediatric unit in Northern California. It was concluded that the organization could support any necessary improvement project needed for a microsystem, primarily a bedside shift report (BSR).

Intervention: The intervention included in this improvement project was staff education through huddle messages and one-on-one discussion about the importance of BSR.

Measures: The process was measured by auditing and observation by this project's assistant nurse manager (ANM) members. In addition, nurse leaders continue to communicate the expectations of BSR to all the staff during the huddle. Finally, all ANMs were asked to observe reports each shift using the BSR checklist for a minimum of five observations per week to understand staff compliance using the BSR audit tool.

Results: The outcome measure shows increased nurse satisfaction when giving and getting reports using standard report sheets. However, the number of audits on bedside shift reporting is lower than expected due to COVID restrictions.

Conclusion: The project demonstrated that evidence-based practices on BSRs improved specific nursing care aspects that influence patient and staff satisfaction, based on survey results.

Keywords: bedside shift report, standard pediatric report, standardization of BSR

Available for download on Wednesday, December 06, 2023

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