Transcript Unit 3 Health-Care Team Communication

Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Unit 3 Health-Care Team
Communication
Group Processes and Patient-Safe
Communication Among Team
Members
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Chapter 12
Patient Safety Communication Risk
Factors in Nursing Work Systems
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Communication Failures Result in
Patient Harmful Events
 Nurses must:
 Learn how communication failures happen
 Recognize risks for communication failure in the work
environment
 Use patient-safe communication strategies specific to
working as a member of the health-care team
 Advocate for health-care system improvements to keep
patients safe
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Communication is crucial to prevent
harmful events in the nurses professional
role
 Patient Monitoring
 Ongoing assessments and evaluation of patient health state to
maintain situational awareness, with the need for communication
with team members for clinical decision making
 Health-care providers form a mental model of the patient’s clinical
situation and make clinical decisions based on the nurse’s shared
essential information
 Coordination of Care
 Communicate to coordinate patient care and services from multiple
members of the health-care team
 Maintaining Continuity of Care During Transitions
 Communicate patient status and plan of care across care continuums
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
The Institute of Medicine Report
44,000 –98,000 deaths occur as a result of medical errors
 One death every 5 – 10 minutes
 Nearly 70% of these deaths related to communication failures
 Cost associated with medical errors is $8–$29 billion annually
 Since 2000, when the report was published, little progress has
been made to reduce the numbers of harmful events
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Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Reducing Patient Care Errors:
Systems vs Personal Approach
 Systems approach
 Recognizes people are fallible and make mistakes
 Does not hold professionals accountable for system failures
 Does not tolerate gross misconduct of individual
 Personal approach
 Blames, names, shames, and retrains individuals committing errors
 “Bad” people make errors
Health-care organizations are
slow in adopting a systems approach
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Failed communication is the reason for nearly 70% of Sentinel Events
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Why Do Errors Occur?
System Approach
 Faulty health-care systems
 Faulty processes within health-care systems
 Poor working conditions
 Lead individuals to make mistakes
 Not the result of individual recklessness of health-care
providers
 Health-care system is the problem and needs to be made
safer
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Health-care errors are symptoms of an
unsafe system
 Conditions within the nursing work system affect human
performance leading to patient-care errors
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More acutely ill patients
Shorter hospital stays
Frequent patient turnover
Extended hours and overtime
Stressful work environment
Interruption-driven environment
High nursing workloads
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Health-care team members will
improve safety by taking a systems
approach:
 Understanding system design and the impact on
safety
 Risk awareness through anticipating and recognizing
safety problems
 Correcting safety problems to prevent harm to
patients
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Systems approach requires knowledge of
human factors science
 Study of the “fit” between people,
 The things they do
 The objects they use
 The environments in which they work.
 If a good “fit” is achieved, it reduces stress on
people
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Human Abilities and Limitations
Affecting Performance
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Human strengths
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Creativity
Adaptability
Flexibility
 Good at finding explanations and meanings from ambiguous evidence and developing a workaround or “quick fix” when things do not work as well as desired
Human weakness: Humans make errors
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90% of all organizational accidents result from human error
Human error is the failure of a planned action to achieve its intended goal
Humans are fallible:
 Cannot maintain continual alertness
 Inability to attend to several things at once
 Have habits of thought and action
 Lack precision in mental functioning
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Normal Cognition Theory: How People
Think During Performance of Activities
 Automatic mode—often repeated, routine
tasks
 Conscious mode—conscious critical thinking in
new situations
 Mixed mode—during trained-for situations
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Types of Human Errors
 Errors of Execution
 The plan is adequate but does not proceed as intended
 Skill-based error—attention or memory failures
 Errors of Decision Making
 The wrong plan is used to achieve an aim
 Rule-based error— apply the wrong rule to a patient situation
 Knowledge-based error—lack of knowledge, lack of information or misinterpretation
 Violations
 Deliberate deviations from standard practices, policies, and procedures
 People purposely break rules with poor operating procedures, inadequate work environments,
low morale, time pressures, and inadequate tools and equipment causing frustration
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
The Nursing Work System
 System defined: Interdependent components that
interact to achieve a common goal
 Nursing work system: Interdependent components
of the health-care system
 Levels of hierarchy:
 Higher levels provide context for lower levels (context = policies,
procedures, norms, technologies, physical environment, people)
 Changes at one level affect all other levels, affecting individuals,
groups, or the organization
 Higher-level decisions can exert influence that unexpectedly
contributes to work conditions that lead to human error
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Concept Map of the
Nursing Work
System
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
The Nursing Work System
 Performance inputs—guide the nursing work system
 Process—changing inputs into outputs through human
behavioral performance
 Performance outputs—outcome of the inputs and process
 System inputs influence nurses’ ability to perform work
activities that will affect patient outcomes
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A well-functioning system can facilitate performance
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A poorly functioning system creates conditions that lead to
human errors
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
How System Factors
Create Hazardous Conditions
 Accident Causation Theory
 When system components across levels function well
together, they collectively serve as barriers to prevent harmful
events
 E.g., adequate staffing and appropriate workloads
 When weaknesses in the system interact in a way to breach
barriers, harmful events occur
 E.g., inadequate staffing and heavy workloads
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
System Defenses as “Swiss Cheese”
 System defenses have many holes
 These holes continually open, close, and shift
 Harmful events happen when the holes in
many successive system levels momentarily
line up and propel a trajectory of error leading
to a harmful event
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Model of the Swiss Cheese Nursing Work System
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
System defense holes occur for two
reasons
 Active failures—unsafe acts that are human errors
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Attention slips
Memory lapses
Honest mistakes
Intentional violations
 Latent conditions—flaws within the work system due to
decisions made by managers and top-level administrators
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Poorly designed facilities
Training gaps
Staff shortages
Heavy workload
Inadequate communication processes
Faulty policies and procedures
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Mental Antecedents to Active Failures
and Unsafe Acts
 What goes on in the mind of the health-care
provider prior to an active failure with an
unsafe act
 Distraction, momentary inattention, forgetting,
losing the picture, preoccupation, fixation
 Environment can be hectic, demanding, timepressured, and inadequately staffed
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Systems Approach:
Focus on Latent Conditions
 Determine underlying cause for active failures
 Focus on changing conditions in the system that contribute
to human error
 Nurses who have the greatest contact with patients are
positioned to detect and correct health-care errors before
they reach the patient
 Nurses must speak assertively about latent conditions
 Nurses must develop situational awareness of the high-risk
environments in which they work
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Nurses must identify and correct latent
conditions in the nursing work system
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Unworkable procedures
Unrealistic policies
Design deficiencies in nursing work areas
Error-provoking conditions leading to unsafe acts (overburden human limitations)
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Time pressures
Heavy workload
Understaffing
High cognitive demands
Interruptions
Long hours
Inadequate training
Unavailable essential information
Inadequate communication processes