Medication changes are passed on by word of mouth
A change made after the form was written is told to whoever is nearest, and it reaches the next shift only if the person who made it is there and remembers. Nurses, the pharmacist and the doctor all describe the same route. The junior doctor assumes telling the nearest nurse is enough.
“If the nurse who made the change is off on her break, it can stop with her.”Staff nurse, 12 years in role
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“If the nurse who made the change is off on her break, it can stop with her.”
Staff nurse, 12 years in role
Open the conversation
LontraTo start, what happens at handover on your ward, from the moment the shift changes?
Staff nurseEarly shift comes in for quarter past seven, we sit in the office for the report from the night nurse in charge, then we go round the bays. In theory. We've got twenty-eight beds, so it's the form plus whatever people say.
LontraWhat is on the form?
Staff nurseReason in, mobility, diet, allergies, drugs as per chart, obs. I've shared a copy, the blank one.
LontraThank you for the form. The medication line reads 'as per drug chart'. If a dose was changed at four in the afternoon, where would that go on this form?
Staff nurseNowhere, really. You'd write it in the Other box at the bottom if there's room. There's room for about one line. More often it just gets said.
LontraWhat does 'said' look like?
Staff nurseIn the office, or at the bedside, if the person remembers. If the nurse who made the change is off on her break, it can stop with her.
LontraCan you give me an example from a recent week?
Staff nurseTuesday, on a late. I'd had a change at four, the timing of a dose. I'd written it on my own scrap of paper and it never made it onto the form. At eight the night nurse asked me about that bed and I told her. If she hadn't asked about that bed, I'd have gone home.
LontraWhat did it cost, that time?
Staff nurseNot much. Ten minutes of me reading her my scrap and her writing it up. But that was because she asked.
LontraHow often does a change like that happen?
Staff nurseMost shifts, something. On a medical ward there's always something moved in the afternoon.
LontraWhat is the first hour of a shift like, for you?
Staff nurseYou're double-checking. I open the chart for every patient, in case. It takes most of the first hour before I trust I know what's happened.
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“Verbally. Medication changes, mostly.”
Staff nurse, 3 years in role
Open the conversation
LontraWhat happens at handover on your ward?
Staff nurseNight staff give us the report in the office, ten minutes, then a quick walk round the bays. It's supposed to be at the bedside. A lot of the time it's the station. Who's who, the plan, what's different.
LontraHow does the 'what's different' part get passed on?
Staff nurseVerbally. Medication changes, mostly. There's no line for them on the form, there's a little box at the bottom that says Other. I put 'see chart' in it half the time.
LontraWhy 'see chart'?
Staff nurseBecause writing it takes a minute and I've got six patients to give. And honestly, the chart's right there.
LontraWhat does the chart show?
Staff nurseWhat's current. It doesn't show that something changed at four. So you read the chart and think it's always been that. It looks the same either way.
LontraHow long does the report take when it's busy?
Staff nurseTen minutes if we're lucky. Twenty-five if someone's rung from A&E, or a call bell, or the phone. It gets cut short, then I do the bedside bits on my own.
LontraWhat do you do in the first hour?
Staff nurseCheck the notes for my six against what I was told. Ring the last shift if something doesn't match. Twenty minutes, maybe, most mornings.
LontraIs there anything you would change?
Staff nurseA line for 'changed this shift' on the form. Even just a tick box. At least it would make people say it.
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“Word of mouth. I tell the nurse looking after the bed and the doctor.”
Ward pharmacist, 5 years in role
Open the conversation
LontraHow do you hear about medication changes on the wards?
Ward pharmacistI see the chart, so I see what's current. I don't see what was done at four unless someone tells me. I'm on each ward at ten and at two, so I see about half of a day's changes.
LontraWhen you recommend a change, how does the ward find out?
Ward pharmacistWord of mouth. I tell the nurse looking after the bed and the doctor. It's not on the form, I've no way of putting it there. Sometimes I leave a sticky note on the chart folder, which is a terrible idea, but it's what I've got.
LontraHow many changes are made in a day on a ward?
Ward pharmacistEight to ten, if I had to guess. Not all of them matter much. I haven't counted and I don't know of anyone who has.
LontraWhat do nurses ask you?
Ward pharmacist'Has that gone in?' I get asked it a lot. It's because they can't tell from the chart whether something's new.
LontraWhat would help?
Ward pharmacistA way to flag 'changed today' on the chart itself. Not on a separate form. It seems obvious.
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“I change the chart and tell whoever's nearest. I assume that's enough.”
Junior doctor, second year
Open the conversation
LontraWhat happens after you change something on a chart?
Junior doctorI tell the nurse who's nearest, or the bay's nurse if I can find them. Then I carry on.
LontraDo you know whether it reaches the next shift?
Junior doctorI assume so. I change the chart and tell whoever's nearest. I assume that's enough.
LontraWhat makes you assume that?
Junior doctorThe chart's the record. It's what I was taught. I didn't know there was a separate handover form until you asked.
LontraWhen do you make most of your changes?
Junior doctorAfter the ward round, three, four o'clock. Right before the late shift hands over. Which I suppose is the worst time.
LontraIs there a way to flag a change for handover?
Junior doctorThere's a free-text box on the electronic note. I don't know who reads it.
LontraWould you do anything differently if you knew?
Junior doctorI'd tell the nurse in charge as well. That's easy, I just don't think of it.
