Improve communication with the right tool

Poor communication major cause of adverse errors

Abington (PA) Memorial Hospital will soon roll out a pilot program for a planned SBAR (situation background assessment and recommendation) initiative the program’s proponents say will improve communications and reduce errors at the facility. The link between poor communication and errors is well recognized in the health care community. In fact, the Joint Commission on Accreditation of Healthcare Organizations recently identified communication as a major cause of adverse events.

“We’ve had instances where there have been adverse events, and where we did not see proper communication, and it turns into a doctor/nurse ‘he said, she said,’” notes Doron Schneider, MD, associate program director, internal medicine residency, at Abington. “People say they were not aware of certain vital signs, or the primary nurse’s concern was ‘X,’ and the physician thought it was ‘Z.’ We want to make sure that when the physician makes an important call, they have received all the pertinent information,” he explains.

“We’ve noted 60% to 70% of medication errors are related to communication, so the way we deliver information and anticipate delivery as a receiver of information can go a long way to alleviating some patient safety problems,” says Schneider.

Interestingly, Schneider and some of the nursing leadership at Abington both heard about SBAR within a short period of time — at separate industry meetings. “It was initially introduced to me at the National Patient Safety Foundation meeting last year in Boston, and a month later, our nurse leadership went to a conference and also heard about it,” he recalls. “It’s a tool that is really gaining acceptance nationally.”

At the heart of SBAR is a form that is filled out and shared with the other health care professionals treating the patient. It is divided into four sections:

  • Situation: This includes patient identification information, code status, vitals, and the nurse’s concerns.
  • Background: Information is noted on patient’s mental status, skin condition, and whether he or she is on oxygen.
  • Assessment: Here the nurse indicates what he or she believes to be the problem.
  • Recommendation: Physician follow-up actions are suggested, including possible tests.

Before a potential rollout to the entire hospital, Schneider says a pilot program will be conducted in the critical care unit (CCU), as part of a totally new overall approach to quality. “The tool is not going to start as a permanent part of our medical record, but it will be on the nurse’s flowsheet as a reminder of how to communicate information surrounding unstable changes in clinical status,” he explains.

In short, it will serve as a unidirectional form of communication — someone on the ground reporting up the chain of command. “It will communicate something of importance from nursing to the physician,” Schneider says. “We will later be looking at how residents communicate with attending physicians.”

Education of staff is critical, he continues. “We want to make sure we not only educate nursing about the fact that we expect them to use this tool, but we also will educate the docs, so they know they are supposed to receive this information.”

This will start with the residents, who will receive a revamped introduction/orientation to CCU when they rotate, which they do monthly. “They will hear about things they have not heard about before, like goal-setting checklists, a bundle project to decrease CAP [community-acquired pneumonia], insulin drips that are now pretty much protocol — a lot of quality initiatives,” Schneider notes.

“As part of that, they will be oriented to SBAR, so that when a nurse talks to them in a way they were not previously used to, they will understand what they are communicating.”

Once the nurses have been educated, he adds, “We want to make sure they have reviewed the chart, know the admitting diagnosis, know the right doctors to call, have an updated meds list, and have the latest vital signs — even before they make the call [to the doctor].”

At the end of the pilot program, residents and nurses will be debriefed. “We will be able to look very quickly at their attitudes and experience, to see if the form has validity and if people think it helped,” Schneider says. “The real outcome, of course, will be a decrease in adverse events and fewer transitions to a higher level of care — once the tool has been rolled out to the general medical floors.”

Eventually, the form will become part of the record. “The nurses will just pull one of these sheets out, and it will almost be like a fill-in-the-blank,” he predicts.