Any discussion of communication in healthcare must include the process of transferring patients and their vital medical information from one provider to another and/or from one healthcare setting to another. Such transfers are known as healthcare handoffs; examples include when a patient is transferred from an ambulance to an ED or when a surgical patient is moved from the recovery room to a surgical floor.A person-to-person handoff takes place when, for example, a physician going off duty signs off to the evening on-call doctor or when nurses report to each other at shift changes. Handoffs are specific circumstances in healthcare that are prone to medical errors. With every transfer of information, there is significant risk that a vital piece of the patient’s medical puzzle will be misread, misunderstood or omitted. Evidence clearly points to many cases where the wrong patient has been handed off!
Healthcare handoffs have traditionally been fraught with a host of problems and complications. To the detriment of patients, providers face a multitude of barriers that hinder the successful and efficient transfer of correct medical information, not to mention patients themselves!
Over the past decade, there have been changes in the way providers communicate with each other. Traditional nursing shift reports, clinician sign-offs and patient transfers were often unorganized and did not follow any standard set of guidelines to ensure completeness and correctness of patient information. Following the wake-up call provided by the Health and Medicine Division’s (formerly Institute of Medicine) report “To Err is Human,” attention was then focused on communication as a root cause of many medical errors. Ongoing research and review of sentinel events led The Joint Commission to conclude that handoffs were significant contributing factors to facilitating communication errors.
During the decade following the publication of “To Err is Human,” The Joint Commission continued to address this issue, and a new requirement entitled “Standardizing Communication Handoffs” was added to the 2006 National Patient Safety Goal “Improve the Effectiveness of Communication among Caregivers.”
The new requirement called for the creation of a handoff process that includes the following elements:
- It provided an opportunity for providers to engage in two-way conversations.
- The receiver of information must have ample opportunity to ask questions concerning the patient’s medical information.
- The handoff must include the most recent data and information concerning the condition, treatment, care plan and services required for the patient.
- Any recent changes or anticipated situations must be included as well.
- To ensure that the information provided during the handoff was correctly received, providers are obligated to verify understanding.
- Strategies to confirm understanding must be used, including the read-back technique.
- The receiving provider must be given appropriate time to review patient history, including previous treatment, services and care plan.
- Finally, efforts must be made to eliminate or limit interruptions during the handoff. Interruptions, as studies indicate, are major contributing factors in adverse events that cause patient morbidity and mortality.
Research has provided clear evidence that successful handoffs decrease the number of communication errors, thus reducing unnecessary and preventable medical mishaps. There are several techniques available to improve the quality and efficiency of handoffs in healthcare settings. Many of these techniques were first created as military strategies and later adopted for industry use; recently they have been modified to improve clinical patient care and safety.
The SBAR system is one such example that has been met with a great deal of success. Originally designed for use in nuclear submarines, it was adapted for patient care settings by Dr. Michael Leonard and co-workers at Kaiser Permanente.
SBAR is currently being used throughout the healthcare industry. This method provides an organized process for passing on pertinent patient information from provider to provider. Before the transfer takes place, vital patient information is entered onto an organized worksheet format to be communicated to the next provider during the handoff conversation.
There are four basic elements on the SBAR worksheet. Each of the letters in the acronym represents one of the elements that must be described by the transferring provider and completed on the worksheet:
- S - SITUATION: What is the patient’s situation? What is going on?
- B - BACKGROUND: What are the patient’s history and background?
- A - ASSESSMENT: What is the patient’s problem?
- R - RECOMMENDATION: What can be done to correct or improve the problem?
A 67-year-old male patient was transferred to an intensive care unit directly from the cardiac catheterization unit. He had required emergency angioplasty of the right coronary artery. The patient had been recovering in the cardiac catheterization unit. Upon arrival from the cardiac catheterization unit, his orders were to remain flat on his back for 6 additional hours, check vital signs, perform site checks for hematoma/bleeding, and distal pulse checks every 15 minutes for one hour, then every four hours.
Upon arrival, the dressing was dry with a scant amount of old bloody drainage and a small but noted hematoma at the insertion site. The patient’s vital signs and pulses remained within normal limits. He requested and received 2 acetaminophen tablets orally during the early evening hours for a headache, without relief. In the morning when the day shift personnel arrived, the patient again complained of a headache. The day shift nurse received an order for acetaminophen #3 (with codeine) from the covering physician who was still on call.
Later that morning, the patient’s mental status changed; shortness of breath was noted, and the size of the hematoma at the insertion site had increased. A diagnostic evaluation of his condition revealed an intracerebral hemorrhage.
This case demonstrates an incomplete and inefficient transfer of medical information during the handoff. As it turns out, the patient in question received anticoagulant therapy during the cardiac catheterization. Even though the treatment information was written on the catheterization procedure record, there was no verbal mention of the anticoagulant medication during the transfer of information from the cardiac catheterization nurse to the receiving RN in the intensive care unit.
Although the nursing staff was initially following frequent vital signs and observing the insertion site for evidence of bleeding, the signs and symptoms of a cerebral hemorrhage were not specifically being considered. When the patient complained of a headache, neither the nursing staff nor the on-call physician considered this symptom a possible warning. Perhaps if the on-call doctor had been aware the patient received anticoagulants during the catheterization, appropriate laboratory studies would have been obtained. Or perhaps if the transferring nurse verbally reported that the patient recently received anticoagulants, the receiving nurse might have anticipated a possible bleeding episode and suggested that the physician order a laboratory clotting or coagulation study.
The Joint Commission calls for a standardized and effective handoff process. If the SBAR system had been utilized in this case, there would not only have been an SBAR worksheet outlining the important medical data of this patient, but there would have been a full conversation covering the data outlined; furthermore, there would have been ample time for questions and answers.
In this case, if the SBAR system had been used:
- The S (Situation) would have explained that the patient was stable without signs of significant bleeding following angioplasty of the right coronary artery; it would have noted, however, that the patient did receive anticoagulant therapy.
- The B (Background) would have most likely stated that this 67-year-old otherwise healthy male underwent cardiac catheterization with emergency angioplasty for recent onset of chest pain.
- The A (Assessment) should have indicated that this post-catheterization patient with angioplasty was stable with normal vital signs, with only a minimal amount of dried blood at the insertion site. The assessment would have noted that there were no signs or symptoms of internal bleeding.
- Finally, and perhaps most importantly, the R (Recommendation) could have indicated that the patient be monitored closely for signs and symptoms of a site hematoma as well as internal and cerebral bleeding. In addition, since the patient received anticoagulants and no coagulation studies were ordered, the receiving nurse might have contacted the physician to request appropriate laboratory orders.
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