NU108 Unit 5 Team Analysis Example

A Potassium Result Nobody Owned: A Team Analysis of One Evening Shift Change on a Composite Medical-Surgical Unit, Mapping Who Held Which Decision and Where a Pending Lab Fell Between Two Handoffs

[Student Name]

Purdue University Global

NU108: Health Professions Transitions

Unit 5 Team Analysis

[Instructor Name]

[Date]

The unit, staff and patient are composite; times and values are bracketed where illustrative.

The Team and the Shift Change

The unit cares for [28] adult patients. At 7 p.m., day-shift registered nurses hand off to night-shift nurses at the bedside. Each nurse has five or six patients. A charge nurse coordinates admissions and staffing and receives a brief report on unstable patients. Two nursing assistants take vital signs and help with mobility. A hospitalist physician covers the unit overnight by phone and pager, and a pharmacist is available by phone. The patient at the center of this analysis, [Mr. A.], a composite 72-year-old, was admitted with pneumonia and acute kidney injury. His afternoon potassium was [5.4], and at 6 p.m. the day hospitalist ordered a repeat level.

Who Held Which Decision

Mapping decision rights explains why the result was missed. The day nurse held the decision to follow up on the pending lab until handoff. The night nurse held it after handoff, but only if she knew about it. The charge nurse held decisions about workload and escalation for the unit, not individual lab results. The hospitalist held the decision about treatment once informed. The laboratory's critical value policy required a phone call only for potassium above [6.0], so a result of [5.9] would be posted to the chart without a call. Nobody on the team was wrong to assume someone else had the result; the system had left it with no one.

The Nurse-to-Nurse Handoff

The day nurse used the unit's handoff tool, organized as situation, background, assessment and recommendation (SBAR), a format designed to give clinicians a shared structure for exchanging information (Haig et al., 2006). She reported the diagnosis, the afternoon potassium, the IV fluids running and the plan for a renal ultrasound. The repeat potassium was not mentioned, because the SBAR template on the unit had no field for pending tests, and the order had been placed by the physician less than an hour earlier.

The handoff covered everything the template asked for; the pending test was lost because the template never asked.

A systematic review of handoff mnemonics found dozens of formats in use, with SBAR the most common, and noted that few had been tested for their effect on what information actually reaches the next clinician (Riesenberg et al., 2009). The Joint Commission has warned that handoffs often omit pending tests and follow-up tasks, and it recommends standardized tools that include them and time for questions (The Joint Commission, 2017). The missing item in this case was exactly that kind of open task.

How the Result Was Found

At 9:10 p.m., the night nurse reviewed Mr. A.'s chart before giving his evening medications and saw the result of [5.9], posted at 7:05 p.m. She checked his heart rhythm on the monitor, which showed peaked T waves, and called the hospitalist. She also told the charge nurse, who checked whether any other patient on the unit had a result posted since shift change that no one had reviewed; none did.

The Report to the Physician

The night nurse used SBAR for the call. Situation: potassium [5.9], posted two hours earlier, with peaked T waves on the monitor. Background: pneumonia with acute kidney injury, afternoon potassium [5.4], on IV fluids without potassium. Assessment: rising potassium in a patient with reduced kidney function, now with electrocardiogram changes. Recommendation: she asked whether the physician wanted treatment started and a repeat level drawn. The hospitalist ordered treatment and a repeat in two hours. The structured call took under three minutes and left no ambiguity about what was needed.

Where Information Was Lost and Protected

Information was lost at two points: in the handoff, where the template lacked a pending-tests field, and in the laboratory policy, where a value just under the critical threshold did not trigger a call. Information was protected at two points: the night nurse's habit of reviewing results before medications, and the structured call to the physician, which turned a found result into prompt action.

What the Team Could Change

Three changes would address the gaps. Adding a pending tests field to the handoff template would make the question routine. A brief joint review of new orders placed in the last hour before shift change would catch tests ordered late in the day. And the unit could ask the laboratory whether results near the critical threshold for patients with kidney injury should prompt a call. Each change targets the system rather than the individual nurses, who acted reasonably with the tools they had. The night nurse's habit of reviewing results before medications should also be shared at the next staff meeting, since it was the step that caught the problem, and a habit that protects patients is worth making a standard rather than leaving it to one nurse's routine.

References

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. The Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Riesenberg, L. A., Leitzsch, J., & Little, B. W. (2009). Systematic review of handoff mnemonics literature. American Journal of Medical Quality, 24(3), 196-204. https://doi.org/10.1177/1062860609332512

The Joint Commission. (2017). Inadequate hand-off communication (Sentinel Event Alert No. 58). The Joint Commission.