Date of Graduation

Spring 5-17-2024

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Scout Hebinck, MSN, RN-C


Problem Handoff report is a significant source of medical error, as reported by the Joint Commission. As it stands, Hospital A’s peripartum mesosystem has no standardized policy regarding the Nurse Knowledge Exchange (NKE) process. Context Hospital A is an urban tertiary care medical center in San Francisco, with its peripartum mesosystem divided into two floors with a total of 35 dedicated beds. Intervention Stakeholder engagement, literature review, and mesosystem analysis identified potential barriers to bedside NKE. To address the identified causes, the project implemented a standardized handoff guide and staff education. Measures The outcome measured was comprehensiveness of NKE as evaluated by a binary coding system. Results NKE comprehensiveness improved significantly when utilizing the bedside handoff guide with an increase from 33.5% at baseline to 77%. Comprehensiveness of NKE regardless of location rose from 74% to 91%. Conclusion The intervention was found to successfully improve NKE comprehensiveness. To ensure ongoing success of this change, continuous leadership support and further PDSA cycles must be pursued.