Transcript Unit 3 Health-Care Team Communication

Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Chapter 13
Health-Care Team Collaborative
Patient-Safe Communication
Strategies
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
High-Reliability Organizations
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Sustain an organizational culture of safety
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Commitment to safety that permeates all levels of an organization, from frontline personnel to
executive management
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Build safety into operations
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Use specific communication strategies to maintain collaborative working
relationships; coordinate and synchronize activities
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Have very low rates of harmful events
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Health care organizations are typically NOT high-reliability organizations
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Culture of Safety
 Commit to safety at all levels
 Acknowledge high-risk situations
 Encourage voicing concerns of threats to safety before harm
occurs
 Encourage reporting errors and intercepted errors within an
atmosphere of trust
 No fear of retribution for reporting errors
 Learn about errors to make safety improvements
 Focus on why and how errors happen
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
“Just Culture”
The Systems Approach
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Systems approach
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Recognizes people are fallible and make mistakes
Does not hold professionals accountable for system failures
Does not tolerate gross misconduct of individuals
Personal approach
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Traditionally used in health-care organizations
Unrealistic expectation of perfection of professionals
Blames, names, shames, and retrains individuals committing errors
Belief that “bad” people make errors
Errors and near misses often unreported
Health-care organizations are
slow in adopting a systems approach
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
High-reliability organization systems
approach based on:
 Knowledge of communication principles and processes
 Knowledge of group process and teamwork principles
 Knowledge of strategies and tools to prevent harmful
events
 Knowledge of an organizational culture of safety
 Knowledge of standardized processes to create shared
mental models of patients’ situations
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Patient Safety Through Group
Collaboration: Shared Mental Models
 Health-care providers must develop processes to
form shared mental models of patient clinical
situations
 Health-care providers make clinical decisions
based on shared essential patient information
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Patient Safety Through Group
Collaboration: Shared Mental Models
 Health-care providers must develop processes to form shared
mental models of patient clinical situations
 Health-care providers make clinical decisions based on shared
essential patient information
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Example:
Concept Care Map to Form a Shared Mental Model
Team members have a clear picture of the medical and nursing
problems, with integration of pathology, medications, treatments,
and laboratory and diagnostic testing
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
6.Impaired Urinary
Elimination
I=2200
O=1800
Polyuria
3+sugar
Not Sure
Acetominophen?
Widower?
Concept Care Map
5.Impaired Physical
Mobility
Fall risk-4
OOB/chair
Weakness
Pressure Ulcer Risk-9
4. Impaired Tissue
Perfusion,
Peripheral
Hx hypertension
138/92
98.4-77-18
VS qid, TPR
Valsartan
Newly Diagnosed Diabetes
Signs & Symptoms of
hypoglycemia, hyperglycemia,
blood sugar, food intake, VS
1.Imbalanced Nutrition:
Less than
Body Requirements
Polydipsia
I=2200
O=1800
Weakness
Humulin N
Glucose (450) 120
Accu-check
Glyco Hgb 12%
Cholesterol 240
1800 ADA
3. Readiness for
Enhanced Knowledge
2.Anxiety
Expresses concern
Over Performing
Injections
Diet
Diagnosis
Medications
Diet
Skin Care
Foot Care
Exercise
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Promoting Effective Health-Care Team
Communication and Collaboration
Standards for Team Communication
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Be respectful and professional
Listen actively
Try to understand the other person’s viewpoint
Model an attitude of collaboration, and expect it
Identify the bottom line; decide what is negotiable and nonnegotiable in patient care management; e.g., patient safety is
not negotiable; when staff members take a break is negotiable
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Standards for Team Communication
 Acknowledge the other person’s thoughts and feelings
 Pay attention to your own ideas and what you have to offer
the group
 Be cooperative
 Be direct
 Identify common, shared goals and concerns
 State your feelings using “I” statements
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Standards for Team Communication
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Do not take things personally
Learn to say “I was wrong” and “You could be right”
Do not feel pressure to agree instantly
Think about all possible solutions before a meeting, and be
willing to adapt if a more creative alternative is presented
 Recognize that negotiation and resolution of conflict take time
and may require several interactions
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Group Process
 An understanding of the behavior of people in groups
trying to solve problems and make decisions
 Principles apply to health-care team processes
 All members of the team must be trusted and respected
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Share information
Help each other when needed
Resolve conflicts
Have high levels of communication competence
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Classic Group Process
 All team members must understand group
process
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Forming
Storming
Norming
Performing
Adjourning
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Classic Group Process
 Forming: Relationship development—team
orientation, identification of role expectations;
beginning team interactions, explorations, and
boundary setting
 Storming: Interpersonal interaction and
reaction—dealing with tension, conflict, and
confrontation
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Classic Group Process
 Norming: Effective cooperation and collaboration—
personal opinions are expressed, resolution of
conflict with formation of solidified goals and
increased group cohesiveness
 Performing: Group maturity and stable
relationships— team roles become more functional
and flexible, structural issues are resolved leading to
supportive task performance through group-directed
collaboration and resource sharing
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Classic Group Process
 Adjourning: Termination and consolidation—
team goals were met, closure occurs after
evaluation, and review of outcomes
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Team Leader: Coordination of Health-Care Team
Patient-Safe Communication Behaviors
 An effective team leader:
 Organizes the team—utilizes resources to maximize
performance, balance workload, and delegate tasks and
assignments as appropriate
 Articulates clear goals
 Makes decisions based on input of team members
 Empowers team members to speak up and openly challenge,
when appropriate
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Team Leader: Coordination of Health-Care Team
Patient-Safe Communication Behaviors
An effective team leader:
 Promotes and facilitates good teamwork; e.g., briefs, huddles,
debriefs
 Resolves conflict; e.g., uses the two-challenge rule, CUS, and
DESC
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Team Briefs
Coordination and Collaboration
Briefs—Planning sessions
 Designate team roles and responsibilities
 Establish team goals
 Develop short- and long-term plans
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Team Huddle
Coordination and Collaboration
Huddle—Problem-solving sessions
 Touch-base meetings to gain awareness of new
developments in a situation
 Discuss emerging events, express concerns
 Anticipate contingencies and anticipate outcomes
 Adjust plans and reallocate resources to meet changing
needs of situation
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Team Debrief
Coordination and Collaboration
Debrief—Group process to improve team performance next
time
 Informal feedback session with informal information
exchange
 Designed to improve team outcomes
 Accurate reconstruction of key events
 Analysis of what worked and what did not
 Revise plans focused on what should be done differently next
time
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Conflict Resolution
 Patient advocacy and assertion
 Advocate for the patient: When you believe
patient safety is in jeopardy and you do not agree
with the primary decision maker (physician)
 Use assertiveness in a firm and respectful manner
to indicate a correction in care of the patient
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Conflict Resolution: Two-Challenge Rule
 When an initial patient-safety assertion is
ignored:
 It is your responsibility to voice your concern at
least 2 times to make sure it was heard
 The team member must acknowledge that it was
heard
 If the outcome is not acceptable:
 Contact a supervisor
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
How to Make Assertive Statements
Using the Two-Challenge Rule
 Make an opening-: “Dr. ____, Mr./Mrs. ___ is supposed to be
discharged.”
 State the concern (#1 challenge): “I am concerned about the
patient’s BP and pulse, which are substantially elevated (patient
admitted for an MI)
 Physician says, “Don’t worry about that.”
 Restate the problem (#2 challenge)- “The patient is supposed to be
discharged, but these appear to be significant alterations.”
 Offer a solution: “Would you assess the patient further?”
 Reach an agreement: Physician further assesses, or sends a
resident, or says not to worry.
 If physician fails to address concerns, contact a supervisor.
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
ASSERTIVE STATEMENTS to Promote
Conflict Resolution Using CUS
 C: “I am Concerned.”
 U: “I am Uncomfortable.”
 S: “This is a Safety issue.”
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Conflict Resolution Using DESC
 Sit down and discuss work-related conflicts; can be done with
a supervisor present or between two professionals
Strive for consensus and a win-win outcome:
 D—Describe the situation
 E—Express concerns about the situation
 S—Suggest alternatives and seek agreement
 C—Consequences of behaviors that are blocking
attainment of team goals
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
High-Reliability Patient-Safe
Communication Strategies
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Guidelines for effective handoff
Medication reconciliation
Guidelines for written documentation in health records
Strategies to avoid errors due to look-alike/sound-alike
medications
 Readback/hearback
 SBAR
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Effective Handoff
During Transitions of Care
 Transfer information during shift-to-shift, unit-to-unit,
hospital-to-long term care facility, etc.
 Ensure:
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All relevant information communicated
Information clearly conveyed, plainly understood
Communications are concise
There is an opportunity to ask questions
Information is clarified
Information is confirmed, validated, and acknowledged by
the nurse assuming responsibility for patient care
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Handoffs should include:
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Diagnosis
Allergies
Current condition
Recent changes in condition
Ongoing treatment
Possible changes or complications that might occur
Plan of action if complications occur
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
High-Reliability Handoffs
 Face to face with interactive questioning
 Topics initiated by person assuming responsibility as well as
by the person being replaced
 Repeating back important information by the incoming
person
 Information presented in the same order every time
 Limited interruptions
 Written summary of activities that occurred during the shift
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Medication Reconciliation at Handoff
During Admission and Discharge
 Almost 50% of medications errors occur during admission and
discharge
 Write complete list of medications taken at home
 Compare list with admission, transfer, and discharge orders, looking
for discrepancies
 Keep list updated
 Communicate list to the next provider
 Keep list in a visible location in the patient’s records
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Guidelines for
Written Documentation
 Write legibly—print drug names and dosages
 Do not use dangerous abbreviations
 Locate “Do not use lists” in each facility:
 Instead of U, u, IU, write units
 Instead of QD, write daily; instead of QOD, write every other day, etc.
 Always use a zero before a decimal point
 0.5 mg
 Do not write a zero after a decimal point because trailing zeros lead to
tenfold dosage errors
 1 mg (not 1.0 mg)
 Use “tall man” lettering for look-alike, sound-alike drugs
 LamiCTAL and LamiSIL
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Readback/Hearback:
Face-to-face and Telephone
 Ensure messages are clearly received and understood
 Sender states information concisely to the receiver
 Receiver first writes down, then reads back what was written
 Sender provides a hearback acknowledging that the readback
was correct or makes a correction
 The readback/hearback continues until shared understanding
between sender and receiver is created.
 Drug doses are expressed in single-digit format, e.g., “14 units of
insulin” verified and read back as: “14-one, four-units of insulin”
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Guidelines for Telephone Communications:
SBAR
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S- Situation
B-Background
A-Assessment
R-Recommendations
Michael Leonard, MD, Doug Bonacum, and Suzanne Graham
Kaiser Permanente of Evergreen, Colorado
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Pre-SBAR: Before Calling the Physician
or Nurse Practitioner
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Assess patient; take complete vital signs
Review medical record for the appropriate physician to call
Know the admitting diagnosis and admission date
Read the most recent physician and nursing notes
Have the medical record available and be ready to report:
Code status, allergies, medications, IV fluids, lab and test
results
 Focus on the problem; be concise
 Review with charge nurse/resource staff/preceptor prior to
calling
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
S: Situation
 State your name and your department
 (say) I am calling about: (patient name, room number, code
status)
 (say) The reason(s) I am calling is (are): (state specific
problem)
 A change in patient’s condition
 Critical lab values
 A lack of response to current treatment/intervention
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
B: Background
 State the admission diagnosis, date, and brief
summary of treatment to date
 State name of the primary physician when
speaking to an on-call physician
 State the relevant medical history
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
A: Assessment
 State the most recent vital signs, oximetry, and pain level
 Give the physical assessment pertinent to the problem,
stating changes from the prior assessment, mental status, and
complaint given by the patient
 State how severe the problem seems to be. Examples: (say) I
think the problem is ________(briefly describe the problem)
or; (say) I am not sure what the problem is, but the patient’s
condition is deteriorating.
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
R: Recommendation
 State what you think needs to be done.
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“Would you consider ______?”
“I need you to _________.”
“I would like to suggest_____.”
“I would like you to______.”
“Would you consider transferring the patient to higher level of care?”
 “I need you to come see the patient.”
 “I suggest ordering/discontinuing medications such as: IVF, antibiotic, transfusion,
pharmacy protocol, etc.”
 “Would you consider ordering tests such as: CXR, ABGs, EKG, CT for PE, blood
work, etc.?”
 Clarify how often to monitor the patient and under what
circumstances to call again
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
Communication Failures
 Leading safety hazard in health-care organizations
 Result in lack of collaboration, coordination, and
synchronization of patient care
It is critical that nurses develop high-level
communication competence to avoid
communication failures leading to harmful
events
Communication for Nurses: How to Prevent Harmful Events
and Promote Patient Safety
References
References for this content can be found in the
text.
Chapter 12: Pp. 173-175
Chapter 13: Pp. 189-191