Improving Caregiver Communication
According to the Joint Commission, communication failure between caregivers is the leading cause of medical errors in hospitals. Timely communication that is accurate, complete, unambiguous and understood by the recipient reduces errors and results in improved patient safety. As a system, we have taken many steps to improve communication of patient information among doctors, nurses and other personnel.
Gwinnett Medical Center has chartered a team of doctors and nurses who are working together to improve the quality of communication of patient information. The team has made a number of improvements, one of which was adopting the SBAR framework for communicating patient information over the telephone.
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication among members of the health care team. SBAR is an easy-to-remember, concrete mechanism, useful for framing any conversation, especially ones that require a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how among members of the team, which is essential for developing teamwork and fostering a culture of patient safety.
Read Back and Verify Verbal Orders and Critical Test Results
The Joint Commission has issued a number of national patient safety goals related to improving caregiver communication. One of these goals is to ensure that orders and critical test results are communicated accurately over the telephone.
Clinical staff members are trained to first write down, then read back any order that is given over the telephone. This is to ensure that the person who will be acting on the order heard the information correctly the first time.
When nursing, X-ray or laboratory personnel call another caregiver to report a critical test result (for example, a blood test with a seriously abnormal finding), they are required to ask the recipient to write down, then read back the result. Again, the goal is to prevent errors that can result from a breakdown in the communication process.
Safe Medication Orders
The Institute for Safe Medication Practices (ISMP) reports that in far too many cases of medication errors, the underlying problem is prescribers' handwriting. In an example from the ISMP, the physician prescribed Avandia, a diabetes drug. But it was read as Coumadin, a blood thinner. Many jokes have been made about doctors' sloppy penmanship, but illegibility is no laughing matter.
Virtually all of the 3 billion prescriptions issued each year in the United States are still written by hand. We take this problem very seriously and have taken steps to eliminate unsafe abbreviations and sloppily handwritten orders.
The computer application, Sunrise Clinical Manager (SCM), has enhanced the way clinicians enter and manage orders, review test results and reports and document the care provided. A key component of this new system is computerized physician order entry or CPOE, which will allow physicians to directly enter their orders into any hospital computer, thus avoiding risks associated with illegible handwritten orders.
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