Improving Caregiver Communication

 

According to The Joint Commission, communication failure between caregivers is the leading cause of medical errors in hospitals.  Timely communication which is accurate, complete, unambiguous and understood by the recipient, reduces error and results in improved patient safety.  As a system, we have taken many steps to improve communication of patient information between doctors, nurses and other personnel. 

 

SBAR Technique

 

GHS 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 between members of the healthcare 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 between 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 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 break-down 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 this 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. At Gwinnett Hospital System, we take this problem very seriously. We are actively addressing the problem of illegible orders and have taken steps to eliminate unsafe abbreviations from handwritten orders.

 

The computer application, Sunrise Clinical Manager (SCM), is coming soon to GHS and it’s going to change and enhance 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.