Hospitals Implement Communications Standards
Hospitals are developing new communications standards to reduce the number of errors that occur when a patient is handed over to a new nurse or doctor during a shift change, the Wall Street Journal reports. According to the Journal, there is "growing evidence" that communication problems during transfers are the "single largest source of medical error."
In an effort to combat the problem, the
According to the Journal, hospitals generally have "ad-hoc" hand-off arrangements that "vary from unit to unit or even nurse to nurse," resulting in errors that range from giving a patient the wrong medication to reviving a patient who has a "do not resuscitate" order. However, some hospitals recently have developed more formal standards that are helping reduce such errors.
For example, Kaiser Permanente has implemented a communication model that helps nurses and doctors convey the most important patient information in 60 seconds.
The not-for-profit Institute for Healthcare Improvement also is working with hospitals to implement a communication model called SBAR -- an acronym for Situation, Background, Assessment and Recommendation -- which originally was used to quickly brief nuclear submariners during a change in command, the Journal reports. When SBAR was implemented at OSF St. Joseph Medical Center in Illinois in 2004, the rate of adverse events dropped to 39.6 per 1,000 from 89.9 per 1,000 patient days in the first year.
The University Health System Consortium, which includes 95 academic medical centers, recently published guidelines on how to comply with the new JCAHO standards, including how to implement SBAR. The consortium this fall also will offer an online program called "Do No Harm," which will include strategies for improving hand-off communication (Landro, Wall Street Journal, 6/28).