June, No.6 - Rhode Island Medical Society

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182Patient Safety Efforts Target Communication atRhode Island HospitalsMEDICINE & HEALTH/RHODE ISLANDMelinda Morin, MDThe 1999 Institute of Medicine (IOM)report, To Err Is Human, 1 sparked a publicoutcry over patient safety in US hospitals.This has resulted in attention tosystem factors as well as accountability atan individual level. Although technologicadvances have soared in many of ourhospitals, communication - a basic tenetof patient care - has suffered. This articleadvocates for a change in proceduresaround patient “hand-offs” and describesthe efforts at Rhode Island Hospital toreduce iatrogenic injury and liability forpractitioners and the hospital. These effortsinclude standardizing the process,improving communication, and minimizingreliance on the memory of patients,families and practitioners.The accurate transfer of informationbetween teams of caregivers is essentialfor the seamless continuity of care. However,“hand-off” communication hasbeen identified as the major cause of sentinelerror events and delay in treatmentwithin US hospitals. 2 Too often key informationis misstated or misunderstood.Five-year data from CRICO/RMF, themedical malpractice company for theHarvard Medical Institutions, indicatethat handoffs were involved in 268 claimsand suits, with more than half involvinga high severity patient injury. 3 As a result,the Joint Commission has includedthe implementation of a standardizedapproach to hand-off communications,with an opportunity to ask and respondto questions, as one of the required goalsfor 2006 and 2007. 4Communication strategies successfulin other high risk settings are being introducedinto the setting of medical care.Patterson et al 5 evaluated communicationmethods at NASA Johnson Space Center,nuclear power plants in Canada andrailroad and ambulance dispatch centers.Techniques found to be effective included:1) Face-to-face verbal updateswith interactive questioning; 2) Unambiguoustransfer of responsibility; 3)Overhearing others’ updates; and 4) Limitinginterruptions during update. Althoughlogical, these methods are rarelyutilized in current medical practice andshould be mandatory in sign-out at alllevels.Studies of thephysician sign-outprocess reveal it tobe a haphazardevent with greatvariation ininformation contentand process.In the United States, resident-physiciansprovide much of the direct patientcare.Previous work has identified coverageby house staff not primarily responsiblefor the patient (cross-coverage) as a significantcorrelate of risk for preventable adverseevents. 6 Cross-coverage by a differentphysician, principally at night, was afar better predictor of hospital complicationsand errors than was the severity ofthe patients’ illness. With the 2003 mandateof an 80-hour work-week for residents,the number of handoffs has substantiallyincreased. While targeting fatiguerelatederrors, this change has exacerbatedcommunication problems involving thehandoff of patient information.Table 1. SBAR Method of Communication SBAR Tool, Institute for HealthcareImprovement, Copyright Institute for Healthcare Improvement, 2007.
Table 2. SPEAK UP - Poster, The Joint Commission, 2007Studies of the physician sign-out processreveal it to be a haphazard event withgreat variation in information content andprocess. 7 The typical resident sign-out is a“one-liner” including diagnosis and theclinical impression, e.g. the patient is allright. It is often purely task-oriented. Thus,effectiveness of sign-out is currently restrictedby its inadequate content, particularlyregarding the plan of care for patients.Six Sigma is a process-focused businessstrategy aimed at improving quality, reducingcosts and improving efficiency. Thesigma level indicates the defect rate in agiven production or service process. In aneffort to achieve Six Sigma performanceand diminish the incidence of errors, theLifespan Health System, including RhodeIsland Hospital, Miriam Hospital and NewportHospital, is currently utilizing CPOE(computerized provider order entry system).CPOE is the portion of a clinical informationsystem that enables a patient’sprovider to enter an order for a medication,laboratory or radiology test, or procedureusing a computer system that providessome level of clinical alerts. CPOE allowsrapid, up-to-date, intra-hospital informationtransfer that is available, and HIPAA protected,at any computer terminal within anyof the hospitals. Rhode Island Hospital isimplementing a standardized sign-out systemfor resident sign-out that is electronicallylinked to CPOE. This system offers areadily available, cost-effective and userfriendlysign-out method, which could beinstrumental in decreasing reliance on vigilanceand memory, while communicatingthe plan of care.Another identified area of frequentcommunication failures centers aroundthe nurse-physician interaction. SBAR(Situation-Background-Assessment-Recommendation)is a situational briefingtechnique that conveys only the most criticalinformation and is one of several communicationmodels gaining momentum inAmerican healthcare. The SBAR model,which has proven successful in the nuclearsubmarine industry, has been adopted bythe Kaiser Permanente system. (Table 1).SBAR requires that information be communicatedin a standardized, consistentmanner. This method emphasizes the anticipationof what information the otherperson will need, the use of critical thinkingand assessment skills and, of particularimport, the goal of reaching a mutuallyacceptable plan.Undoubtedly, the change to an effectivemodel of communication requiresan enormous change in the very cultureof medicine. It requires a change to concernsabout an abnormality seen, not theperformance of specific tasks. It requiresa team approach, where nurses are notafraid to be wrong and are not afraid tostate that they are worried. It requireschange in the hierarchy of medicine. Physicianswould still be the de facto leaders inpatient management, but would need tobe more accepting of nursing input. Successfulimplementation would ablate thecurrent system of hinting and hoping bynon-physicians. The use of SBAR couldalso be expanded to the other healthcaresettings (e.g. outpatient office or nursinghome settings); incorporation into otherpractice situations (daily rounds, dischargesummaries); or incorporation into othertypes of hospitals outside of academic medicine(community hospitals).SBAR is being introduced into anothervital area of communication atRhode Island Hospital: nursing sign-out.Traditionally, shift change sign-out hasrelied on taped or written report whilephysically separated from the patient.VOLUME 90 NO. 6 JUNE 2007183
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June, No.6 - Rhode Island Medical Society

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