Protokolli i Dorezimit te Turnit te Infermiereve - Rregullore e brendshme e spitalit

The project is managed by Abt Associates under contract 182-C-00-10-00104-00. The primary objective of the policy is to ensure that patient care continues uninterrupted and safely, providing nurses with the necessary information for immediate action. Secure handover will promote patient safety and satisfaction by preventing problematic incidents resulting from poor communication. The handover process involves a standardized report that takes place between two nursing shifts, with the specific goal of communicating patient information to nurses. The report is a critical component of patient care, ensuring minimal loss of essential information, providing a learning opportunity for all nurses, and enabling monitoring and evaluation. The users of this policy include all nursing staff involved in transferring patient information from one nurse to another. The report is conducted by: * The charge nurse responsible for the shift * The shift supervisor responsible for the shift (in the absence of the shift supervisor, a nurse-in-charge) The clients/patients covered by this policy include all patients admitted to the hospital who are under the care of two nursing shifts. The evidence shows that the handover process is a critical component of ensuring high-quality patient care in the healthcare environment. The handover report takes place in most wards three times a day. The handover process may take some time, depending on the number of patients and the number of staff caring for them. The problems that need to be addressed during handover include: * Loss of information (loss of data) including patient information that may be forgotten, poor communication among nurses, and handover not conducted by the responsible nurse * Diversion of attention, including noise, interruptions, and inattention of staff * Lack of confidentiality, including lack of privacy in the nursing area, proximity of patients' relatives to the nursing area * No handover at the beginning of the shift due to delayed arrival of nurses or the handover nurse leaving early The handover format includes verbal and written handover. For written handover, a specific book, "Handover Book," and nursing charts are used for each patient. Recommendations include: * Handover should not be directed solely to the shift supervisor. All nurses taking the shift should be part of it * The start of handover is a good opportunity for the charge nurse to formally hand over medications, medical supplies, and ward equipment to the shift supervisor * Accuracy of the handover report content, whether in the handover book or chart, is a critical factor in ensuring high-quality nursing care * Handover should be disciplined and start on time, and staff members participating in handover should have the necessary information ready at the start of the shift * Written reports in the "Handover Book" (see appendix 1) are made at the start of each handover. This should not take long, taking a few minutes, and should focus on patient safety issues in that clinical area during that shift. This information should be communicated and highlighted in the next shift and should emphasize safety as a top priority * Written reports are much more accurate and take less time than verbal reports. Written reports prevent the possibility of losing vital information that may result in patient morbidity and mortality * Documentation should be clear, concise, and done on a regular basis * Nurses record their observations, knowing that their assessments of patients will be read and evaluated by their colleagues * Nursing charts (appendix 2) should be used by nurses to complete and pass on clinical information about patients. Patient data for completing nursing charts are obtained from the doctor's clinical chart. The charge nurse or shift supervisor is responsible for clearly and legibly writing all therapy prescribed by the doctor in the clinical chart. The standards of handover quality are: * Confidential – Ensure that information is not overheard by those not involved in the process. The handover book and nursing charts should be kept in the nursing area. * Continuous – Start on time, at the beginning of each shift. Use a quiet area with minimal distractions. * Concise – Only pass on essential information; too much information can be confusing. Avoid unnecessary and irrelevant information. Avoid labels and stereotypes. * Accurate – Ensure that all information is correct and not forgotten. Update care plans at the start and end of each shift. Information should be clear and concise, and not use jargon. * The nurse on duty – Continuity is essential; the nurse who cared for the patient should participate in handover. The nurse handing over writes the first letter of their first name, the first letter of their surname, and their signature, the same as the nurse receiving the handover. Audit and monitoring of handover practice should be conducted by the hospital's director and the head nurse. A handover evaluation instrument is included in appendix 3.