When I was a bedside nurse on a pediatric CICU unit, several safety measures were in place to ensure a smooth transition during shift change. Forgetting or not having time to do these safety checks was not an option, as numerous issues could compromise the patient’s health. A small choice to forgo the handoff safety measures at shift change was a shortcut some nurses chose if they felt confident in doing so. In one instance, a nurse forgot or chose not to calculate the drip rates of her continuous infusions at the start of her shift, which was part of the safety measures needed during shift change. This exclusion of ensuring the proper dose of life-sustaining medications are reaching the patient proved to be a monumental mistake. An insufficient amount of medication was delivered, and the mistake was not caught until several hours later. The seemingly small mistake of forgetting to calculate drip rates negatively impacted the patient’s care and endangered their wellbeing. Knowledge of the Chaos Theory would have benefited those involved by understanding that a very small decision or change can have an enormous impact. In research from McGrath (2020), the author’s goal was to improve the very problem stated above: improving handoff communication for patient safety. McGrath identifies ineffective handoff communication in a hemodialysis unit as a risk for errors and jeopardizes patient safety, and a major contributing cause for adverse events. To implement a change in their unit, the researcher utilized Lewin’s Planned Change Theory. This particular theory has three stages: unfreezing, introducing change, and refreezing. Unfreezing involves recognizing the need for change and the driving forces that encourage or resist the improvements. The second step is introducing the change to enhance the process or problem. Refreezing is essentially sustaining the new guidelines placed in stage two. Just as the author in this study, I could use Lewin’s model to “unfreeze” the status quo of leniency towards handoff communication and help others on the unit realize the need for consistency regarding drip rate calculations at shift change. The change itself would be a prompt that each nurse must cosign in the documentation. “Refreezing” would be ensuring the change is maintained by audits and coaching if needed.


Efficient and effective handoff communication is essential in healthcare settings to ensure patient safety and continuity of care. The handoff process involves transferring patient information, responsibility, and authority from one healthcare provider to another during shift changes. It is during these transitions that important patient information can be missed or misunderstood, leading to errors and adverse events (McGrath, 2020).

This assignment aims to explore the use of Lewin’s Planned Change Theory in improving handoff communication and specifically address the issue of inadequate calculation of drip rates during shift change. The incident mentioned in the introduction highlights the potential consequences of not adhering to safety measures during handoff, as it resulted in an insufficient delivery of life-sustaining medication. By understanding the Chaos Theory, which emphasizes the butterfly effect, namely how small decisions or changes can have significant impacts, healthcare professionals can recognize the importance of implementing robust handoff procedures.

Lewin’s Planned Change Theory

According to Lewin’s Planned Change Theory, change occurs through a three-stage process: unfreezing, introducing change, and refreezing (Lewin, 1947). The first stage, unfreezing, involves recognizing the need for change and understanding the driving forces that encourage or resist the proposed improvements. In this case, the lenient attitude towards handoff communication, specifically the calculation of drip rates, needs to be unfrozen. This stage requires raising awareness among healthcare providers about the potential risks and consequences of inadequate handoff procedures.

The second stage of Lewin’s theory is introducing change, where healthcare providers are educated and trained on specific guidelines and protocols to improve handoff communication. In this case, the change would involve ensuring that each nurse calculates the drip rates of continuous infusions and cosigns this information in the documentation. This step aims to emphasize the importance of accurate and consistent calculation of medication doses during handoff to prevent errors and ensure patient safety.

The final stage of Lewin’s theory is refreezing, which involves sustaining the change and ensuring it becomes the new norm. This can be achieved through regular audits and coaching sessions to reinforce the adherence to the new guidelines. By monitoring and providing feedback, healthcare providers can be encouraged to consistently follow the established protocols for calculating and documenting drip rates during handoff. This refreezing stage is crucial to ensure long-term change and prevent a return to the previous leniency.

Application of Lewin’s Model

Applying Lewin’s Planned Change Theory to this scenario allows healthcare professionals to understand and address the challenges associated with handoff communication and the calculation of drip rates. By recognizing the need for change and the potential risks involved, healthcare providers can be motivated to embrace the proposed improvements.

During the unfreezing stage, education and awareness campaigns can be conducted to highlight the importance of accurate calculation of drip rates and the potential consequences of inadequate handoff procedures. Creating a sense of urgency and emphasizing patient safety as a priority can help overcome resistance to change.

The introduction of change stage can involve the development of comprehensive guidelines and protocols for handoff communication, specifically addressing the calculation and documentation of drip rates. These guidelines should be communicated effectively, and training sessions should be conducted to ensure all healthcare providers understand and follow the new procedures consistently.

In the refreezing stage, regular audits and coaching sessions can be conducted to evaluate compliance with the new procedures and provide feedback to healthcare providers. Recognizing and praising adherence to the guidelines can help reinforce the change and create a culture of accountability and patient safety.


Improving handoff communication in healthcare settings is crucial to ensure patient safety and continuity of care. Lewin’s Planned Change Theory provides a framework for implementing and sustaining change. By understanding the potential consequences of inadequate handoff procedures, healthcare providers can recognize the need for change and embrace new guidelines and protocols. Through unfreezing, introducing change, and refreezing, healthcare organizations can establish robust handoff procedures that prioritize accurate calculation and documentation of drip rates, ultimately enhancing patient safety and preventing errors during shift change.