Date of Graduation

Summer 8-14-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


The change of shift is one of the most crucial times during a nurse’s day. It is a time where vital patient information is passed off from one nurse to the next. There is evidence that the root cause of many sentinel events and poor patient outcomes in related to communication breakdown during the change of shift report process. The Joint Commission has identified communication as the primary cause for preventable medical errors with handoffs accounting for 80% of these instances. Change of shift is an elaborate communication process that involves the transition of care between nurses as well as other clinicians. The objective of the clinical nurse leader CNL internship project is to improve patient care outcomes and improve nurse to nurse communication by provide a standardized change of shift report sheet. Educational sessions were performed at change of shift huddles and nurses were provided with a best practice tip sheet to reiterate the key point of good communication. This project was conducted on the medical surgical telemetry unit in a hospital in Daly City, CA. The patient population includes a diverse geriatric population with the average age being around sixty five years old. Although this project was time limited it found to already have a 10% improvement in patient safety outcomes and 15% increase in patient satisfaction scores. Recommendations going forward include encouraging staff to utilize the electronic healthcare record while giving report so that the information that is being exchanged is the most accurate and up to date. It is important for all members of the nursing staff to take ownership in this project for sustainability.

Included in

Nursing Commons