Lecture 5

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Principles of Safety to Effect Safe Collaborative

Interprofessional Communication
Lecture 5
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Unite Two
Upon successful completion of this unite, the student will demonstrate the ability to:

LO 2: Integrate principles of safety to effect safe collaborative inter-professional


communication.
Topics to cover:
1. The Joint Commission guide on improving staff communication
2. The Joint Commission patient-centered communication standards for hospitals
3. The Joint Commission requirements on hand off communication
4. Standardization for effective safe communication (SBAR)
5. Strategies and programs for safe inter-professional communication (STEPPS, patient
centered rounds)
6. The Joint Commission standards on nursing documentation
7. Use of information technology in communication (E- health records)

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Lecture 5

Topics:
1. The Joint Commission guide on improving staff communication
2. The Joint Commission patient-centered communication standards for hospitals
3. The Joint Commission requirements on hand off communication
4. Standardization for effective safe communication (SBAR)
5. Strategies and programs for safe inter-professional communication (STEPPS, patient centered rounds)

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Learning Objectives

1. Explain the role responsibilities of nurses that involve


patient-safe communication.
2. Describe the connection between communication and
patient safety.
3. Describe where communication breakdowns occur and how
they can lead to harmful events.
4. Identify the key organizations that are addressing
communication and patient safety at national and global levels.
5. Understand of how to use the SBAR communication tool.

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Inter-professional Communication and
Patient Safety
• Communication is the key instrument for patient safety used by
nurses and all health-care providers to ensure the ongoing
accuracy and continuity of patient information to promote safe,
quality care.
• Gaps in communication and misinterpretations pose risks to
patient safety and can result in patient harm.
• It is critical that nurses develop high-level competence in
communication and use patient-safe communication strategies
provided by the leading experts nationally and worldwide to keep
patients safe from harm and to build a safer health-care system.
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Connection between Communication and Patient Safety

• The critical connection between communication and patient safety is


that nurses and other health-care providers make clinical decisions,
plan treatments, and perform interventions on patients based on
available information that is communicated between health-care team
members and patients.
• It is important to understand that every aspect of patient care hinges
on how health-care team members, including patients, have
interpreted available information.
• If clinical decisions are based on incomplete or misinterpreted
information, treatments may be planned and performed by health-
care providers that are inappropriate and may cause patient harm.
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Making Clinical Decisions Based on Patient
Sharing of Personal Health Information
• To promote patient safety, nurses and other health-care providers must
communicate with patients in a way that encourages the patients to share
personal health information.
• Nurses and other health-care providers use specific patient-safe
communication strategies to develop, nurture, and maintain the trusting
relationship.
• If patients do not feel a sense of trust in and genuine sincerity from those
involved in their care, they may not share information that is necessary for
accurate decision making and treatment planning.
• Nurses and other health-care providers ensure that they have accurately
identified the patient when gathering health information and prior to
administering treatments; so they can avoid administering the wrong
treatments to patients.
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Ensuring Accuracy: Conveying and Interpreting Messages Accurately

• As important as it is to share essential information to promote appropriate decision making


and patient safety, it is equally important to ensure that the information is conveyed and
interpreted accurately.
• Accuracy in shared patient information is always dependent on the communication skill of
the individual.
• When communicating with patients, nurses must understand that many factors can
interfere with the patient’s ability to convey and interpret messages accurately.
• Nurses must use clear language that is appropriate to the age and stage of development of
the patient to overcome any factors that may interfere with the patient’s ability to interpret
messages accurately.
• When nurses convey information to patients, they seek feedback from them to ensure that
patients have interpreted their messages accurately.
• Nurses and other health-care providers bear the greater responsibility of ensuring accuracy
in communication during their interactions and information exchange with patients.
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Initiatives to Improve Communication and
Patient Safety
• Initiatives to reduce the risk of harmful events caused by problems
with communication have become a national and global focus, led by
such organizations as:
• the U.S. Joint Commission,
• the Canadian Council on Health Services Accreditation,
• the World Health Organization.

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The Joint Commission and the Canadian Council on Health
Services Accreditation
• The role of the Joint Commission and the Canadian Council on Health Services Accreditation is
to examine and improve the quality of care and services provided to patients by health-care
organizations.
• These organizations set the standards of quality care and measure hospitals and other health-
care organizations’ compliance with these standards.
• The Joint Commission and the Canadian Council have developed national patient safety goals
for improving communication among health-care providers.
• There is great opportunity now to integrate patient-safe practices in communication developed
by leading patient safety organizations, which have been endorsed worldwide by safety
experts, nursing and medical profession associations, and health-care organizations.
• “No adverse event should ever occur anywhere in the world if the knowledge exists to prevent it
from happening.”

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High-level Communication Competency needed in Nurse-patient
Relationships.

• In nurse-patient relationships, nurses attempt to develop collaborative relationships with


patients, patient families, and legal guardians to establish mutual health-care goals and
objectives.
• The nurse-patient relationship always includes the patient and will also include the legal
guardians if the patient is younger than 18 or is otherwise unable to make decisions due to
the nature of the health state.
• High-level communication competency behaviors include communication knowledge, skill,
and motivation.
• Communication knowledge means knowing what behavior is best suited
for a given situation.
• Communication skill is having the ability to apply the behavior in the
given context.
• Communication motivation is having the desire to communicate in a
highly competent manner.
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High-level Communication Competency Using the Patient-safe
Communication Process

• A professional high-level communication competency in nurse-


patient relationships, can be developed and achieved by a
systematic, decision-making Patient-Safe Communication
Process.
• The Patient-Safe Communication Process is derived from the
transformational model, which is a model of communicating
competently.

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Patient-Safe Communication Process

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Patient-Safe Communication Process
• The patient-safe communication process enables you to engage the patient
to the highest degree possible—given the patient’s ability—and
collaboratively work with the patient toward the attainment of health goals
and objectives.
• The patient’s health outcomes depend largely on your ability to communicate
with the patient and other members of the healthcare team.
• The patient-safe communication process leads to the recognition of needs,
the establishment of mutual goals, and formation of trusting and collaborative
nurse-patient relationships.
• No matter what the activities the nurse hopes to accomplish with the patient,
use the patient-safe communication process for the highest probablity of
attaining common meaning and positive health transformations.
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Communication of Essential Patient
Information
• Primary activities within the role of the nurse that involve
communicating essential patient information to other health-care
team members include:
• Patient monitoring
• Coordination of care
• Maintaining continuity in care.
• These skills are essential and inseparably linked to patient safety
and prevention of harmful events.

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Organizational Culture of Safety
• It refers to a commitment to safety that permeates all levels of an organization,
from frontline personnel to executive management.
• In a culture of safety, individuals are encouraged to report intercepted errors,
errors, and harmful events, each of which can be discussed in an atmosphere of
trust and mutual respect without fear of retribution.
• A culture of safety analyzes why and how errors happen rather than focusing on
finding the person who might have been responsible.
• High standards of performance are desirable in nurses, physicians, and other
healthcare providers, but such standards can become a serious problem when
they create an expectation of perfection.
• Because nurses and physicians regard perfection as a professional standard,
they feel shame when they make an error, which creates pressure to hide or
cover up errors. As a result, errors are unreported.
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Standards for Team Communication
• In the health-care system, there are too few standards and safe
practices focused on interdisciplinary patient-safe communication
strategies.
• All members of the health-care team must have excellent
communication skills.
• Team members need to have the ability to actively listen and
encourage others, to share in a team member’s success or
failure, and have the capability to know a colleague well.

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Successful Teamwork Model

• Open communication Acknowledgment and


processing of conflict
• Non-punitive environment Clear specifications regarding
• Clear direction authority and accountability
Clear and known decision
• Clear and known roles and making procedures
tasks for team members Regular and routine
• Respectful atmosphere communication and information
sharing
• Shared responsibility for Enabling environment, including
team success access to needed resources
Mechanism to evaluate
• Appropriate balance of outcomes and adjust
member participation for accordingly
the task at hand

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Collaborative Patient-Safe
Communication Strategies
Promotion and facilitation of teamwork by the nursing team leader can be accomplished through the
following patient-safe strategies that are standardized processes from high-reliability organizations and
have been adapted to health-care teams to minimize patient care errors:
Brief
Huddle
Debrief
Resolving Conflict Through Feedback
Two-Challenge Rule
CUS
DESC
High-reliability Patient safe
Communication Strategies
• Communication standardized processes in high-reliability organizations are termed “safety
nets” because they describe behavior expected of individuals that ensures high-quality
performance.
• Health-care organizations have adopted standardized communication processes from high-
reliability organizations to be used as patient-safe communication strategies including:
• Guidelines for effective handoff
• Medication reconciliation at transitions in care
• Guidelines for written documentation in health records
• Strategies to avoid errors due to look-alike/sound-alike medications
• Readback / hearback when accepting and transcribing verbal and telephone orders
• SBAR (Situation-Background-Assessment-Recommendation) tool when communicating changes or
updates in patient condition

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Handoff: A Critical Point of Vulnerability

• A handoff is the transfer of essential patient information and responsibility of care


from one care provider to another for the purpose of ensuring continuity in care and
patient safety.
• It is recognized as the highest point of vulnerability in patient safety.
• Terms in nursing that are synonymous with handoff include report, nursing report, or
shift report. Handoffs occur during the following transitions in care:
• Nurse-to-nurse
• Shift-to-shift
• Unit-to-unit
• Facility-to-facility
• The handoff includes communication methods between the health-care providers
such as verbal, written, or simultaneous verbal and written channels and is
dependent on the health-care providers’ communication competency, level of stress,
fatigue, or overload.
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Handoff: A Critical Point of Vulnerability
• The handoff is a complex process. It must provide accurate essential
information, including the patient’s current status, recent changes in
condition or treatment, anticipated changes in condition or treatment to watch
for, and plans that may be considered to address anticipated events.
• The handoff provides opportunity for the individual who is accepting
responsibility of the patient to bring a fresh perspective to the patient
situation.
• Handoff is an integral communication process between healthcare providers
that promotes effective critical thinking and decision making, maintains
continuity of care, and promotes patient safety.
• The result of inadequate handoffs is that safety often fails, resulting in, for
example, wrong-site surgery, medications errors, mismanagement of critical
results, and patient deaths.
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Handoff: A Critical Point of Vulnerability
‘The quality of handoff influences directly the delivery of care for the
shift that follows’.
• The handoff characteristics that high-reliability organizations
shared included:
• Face-to-face verbal update with interactive questioning
• Topics initiated by the person assuming responsibility as well as the person
being replaced
• Repeating back by the incoming person to ensure information was
accurately interpreted
• Information presented in the same order every time
• Limited interruptions
• Written summary of activities that occurred during the shift
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Handoff: A Critical Point of Vulnerability
• The World Health Organization Collaborating Center and other leading
organizations have developed health-care handoff recommendations.
• The recommendations are:
• Use clear and common language; avoid jargon, ambiguous words, or confusing terms that
are open to misinterpretation.
• Limit interruptions during handoff communications.
• Focus on the information being exchanged; avoid distractions, such as mixing a
medication
or trying to chart at the same time as listening to another’s handoff.
• Allocate sufficient time for handoff.
• Encourage interactive questioning, allowing opportunity to verify and clarify information.
• At minimum, include diagnosis, allergies, current condition, recent changes in condition,
ongoing treatment, and possible changes or complications that might occur and what the
plan of action should be if complications do occur in the next time interval.
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Medication Reconciliation at Handoff

• A key consideration during handoff is the reliability of medication information.


• Medication regimes must be carefully communicated between health-care providers: 46% of
medication errors occur when new orders are written at patient admission and discharge.
• The World Health Organization Collaborating Center has recommended a verification process of
medication reconciliation to prevent medication errors at care transition points:
• Write a complete and accurate list of all medications the patient is taking at home.
• Compare the list against the admission, transfer, and discharge orders, and bring
discrepancies to the attention of the prescribing physician.
• Keep the list updated.
• Communicate the list to the next provider of care whenever the patient is
transferred
from one care unit to another and when the patient is discharged home.
• Keep the list in a visible location on the patient’s chart.
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Guidelines for Written Documentation in Health Records

• In the health setting, the patient’s chart contains the written documentation of
assessments, treatments, and patient responses to interventions and medically
prescribed therapies.
• The chart is a communication tool in which essential patient information is
recorded and shared by all members of the interdisciplinary health-care
team.
• Illegible handwriting and use of abbreviations and symbols create error-prone
conditions in health care.
• Factors such as time pressures, noise, and interruptions can increase the
likelihood of misinterpretations and human error.
• Guidelines for Do Not Use abbreviations and symbols have been developed by
each organization. Health-care agencies can tailor the Do Not Use list specific to
their independent analysis of incidents and harmful events.
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Guidelines for Written Documentation
in Health Records
• Confirmation bias can lead to errors in interpretation of the intended meaning of
written physician orders, so keep these patient safe practices in mind:
• The letters U, u, and IU have been used as an abbreviation for the word “units”;
patient-safe practice: instead of U, u, or IU, write units.
• Written Latin abbreviations, although the norm in medicine, can lead to
misinterpretations; patient-safe practice: instead of QD, write daily; instead of
QOD, write every other day.
• Always use a zero before a decimal point for a fractionated dosage: e.g., 0.5
mg.
• Tenfold dosage errors can also occur with trailing zeros; patient-safe practice:
do not write a zero after a decimal point, and do not use a decimal point for a
non-fractionated drug dosage; write, for example, 1 mg.
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Strategies to Avoid Errors Due to Look-Alike/Sound-Alike
Medications

• With tens of thousands of medications available, over 600 pairs of look-alike


and sound-alike drug names have been reported.
• The potential for error is significant. In terms of look-alike drugs, contributing
to risk of misinterpretation are illegible handwriting, the care providers’
unfamiliarity with drug names, new products, similar packaging, similar
clinical uses, and the failure of pharmaceutical manufacturers to recognize
potential for error prior to approving new drug names.
• The World Health Organization Collaborating Center has recommended that
drug
name differences should be emphasized using methods such as “tall man”
lettering. Examples of tall man lettering are LamiCTAL and LamiSIL.
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Readback/Hearback: Accepting and Transcribing
Verbal and Telephone Orders

• Nurses receive face-to-face and phone orders from physicians and advanced
nurse practitioners for patient medications and treatments on a daily basis.
• They receive critical results over the phone from the laboratory and other
information from radiology and the many disciplines involved in the patient’s
care.
• The transfer of patient information verbally and over the phone translates into
clinical decision-making and nursing actions; therefore, accuracy in
communications is vital to ensure patient safety. A patient-safe communication
strategy for accepting and transcribing face-to-face and phone orders with
accuracy is readback/hearback.

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Readback/Hearback: Accepting and Transcribing
Verbaland Telephone Orders

• Ensuring that messages are clearly received and understood as intended


requires “readback/hearback” described in the following sequence:
The sender states information concisely to the receiver.
The receiver writes the information down first and reads back what has
been written.
The sender provides a hearback acknowledging that the readback was
correct or makes a correction.
The readback/hearback process continues until a shared understanding is
mutually verified.

‘Only the individual giving the verbal order can verify it as accurate against
what was intended’.
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Situation-Background-Assessment-Recommendation (SBAR)

• The adoption of standardized communication tools and behaviors is a very effective strategy in
reducing risk of harmful events.
• This is particularly true when there is a power or authority gradient between two
communicators. For example, in health care, a physician is considered at the top of the
hierarchy and has more authority than a nurse.
• One such tool that standardizes behavior between physicians and nurse is the situation,
background, assessment, and recommendation (SBAR) instrument.
• The SBAR tool for communication includes:
• S—Situation. Describe the problem in a simple sentence. What is going on
with the patient?
• B—Background. What is the clinical background or context? Anticipate the
listener’s questions about the situation, and provide the answers.
• A—Assessment. Summarize your observations about the situation. What do
you think the problem is?
33 • R—Recommendation. Provide a specific recommendation for problem
Situation-Background-Assessment-Recommendation
(SBAR)
• The use of such a tool forces both the sender and receiver to move
through a discussion in a predictable, logical flow that is not dependent on
personality, status or hierarchy, sex, ethnic background, or differences in
communication styles between nurses and physicians.
• It allows health-care providers with differing communication styles to
speak
the same language. It does not leave communication open to chance.
• Briefly and concisely, critically important pieces of information have been
transmitted
in a predictable structure.
• The SBAR develops critical thinking skills as the person initiating the
conversation knows to indicate the problem, provide an assessment, and
indicate appropriate treatments.
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Situation-Background-Assessment-
Recommendation (SBAR)

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Before Calling the Clinician

• Before making your call, you will need to check the following
steps:
• Have I seen and assessed the patient myself before calling?
• Has the situation been discussed with the senior nurse?
• Do I know the admitting diagnosis and date of admission?
• Have I read the most recent medical notes and notes from the nurse
who worked the shift before me?

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Making the Call

• You will need to have the following documents in front of you


when speaking to the clinician:
• the patient’s observation chart, to relay the most recent vital signs;
• list of current medications (prescription chart), allergies, fluid chart;
• any pathology results with dates and times that tests were
conducted, and results of any previous tests for comparison;
resuscitation status.

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The Information we Need to
Communicate Effectively
• So, we know to keep the communication down to brief facts, with
part of the SBAR communication tool keeping to the specifics.
• Situation
• What is the situation you are calling about?
• You will need to identify yourself, your clinical area, the patient
and the exact location.
• You will need to clearly state the problem: what is it?
• When did it happen or start? How severe is the problem?

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The Information we Need to
Communicate Effectively
• Background
• Information related to the situation could include the following:
• the admitting diagnosis and date of admission;
• list of current medications, allergies and IV fluids;
• most recent vital signs;
• laboratory results with date and time that tests were performed, and
results of previous tests for comparison;
• other clinical information;
• resuscitation status.

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The Information we Need to
Communicate Effectively
• Assessment
• You will need to communicate your assessment of the situation,
such as ‘This is what I think the problem is…’: the problem is
cardiac, infection, neurological, respiratory or other;
• I don’t know what the problem is but the patient is deteriorating;
• The patient is unstable and may get worse, we need to do
something.

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The Information we Need to
Communicate Effectively
• Recommendation
• What is your recommendation to the clinician based on the situation
and assessment:
• “I need you to come and see the patient.”
• “I think we need to….”
• “Tell me what should I do next.”
• “Should I contact anybody else?”
• “Should I prepare anything such as any drugs, fluids, procedure
trolley”.

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References
• Institute of Medicine. Page, A. (ed.). Keeping Patients Safe: Transforming the Work
Environment of Nurses. Washington, D.C., National Academies Press: 2004.
• Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission Guide
to Improving Staff Communication. Oakbrook Terrace, Ill., Joint Commissions Resources: 2005.
• Clancy, C.M. Care Transitions: A Threat and an Opportunity for Patient Safety. American
Journal of Medical Quality 1:415-417, 2006.
• Hughes, R.G., Clancy, C.M. Improving the Complex Nature of Care Transitions. Journal of
Nursing Care Quality 22:289-292, 2007.
• Joint Commission. FAQs for the 2008 National Patient Safety Goals. Located at
http://www.jointcommission. org/NR/rdonlyres/13234515-DD9A-4635-A718-
D5E84A98AF13/0/2008_FAQs_NPSG_02.pdf, Accessed July 2020.
• Institute of Medicine. To Err Is Human: Building a Safer Health System: A Report of the
Committee on Quality of Health Care in America. Washington, D.C., National Academies Press:
1999. Located at http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf Accessed July
2020.
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References
• Agency for Healthcare Research and Quality. Instructor Guide for
TeamSTEPPS: Team Strategies & Tools to Enhance Performance
and Patient Safety. Rockville, Md., AHRQ Pub. No. 06-0020: 2006.
• Schuster, P. Concept Mapping: A Critical Thinking Approach to
Care Planning, 2nd ed. Philadelphia, FA Davis: 2008.
• Joint Commission. Sentinel Event Statistics, June 29, 2004. In
Leonard, M., Graham, S., Bonacum, D. (eds.).
• The Human Factor: The Critical Importance of Effective Teamwork
and Communication in Providing Safe Care. Quality and Safety in
Health Care. 13:i85-i90, 2004.
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800 MyHCT (800 69428)
communication@hct.ac.ae
www.hct.ac.ae

Happiness Center
PO Box 25026
Abu Dhabi, UAE

HCT_UAE
hctuae
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