Handoff Reporting and Incident Reporting Week 6

Patient care conferences

can offer opportunities for clarification regarding the overall plan of care for a patient, or they may be a venue for resolving difficult ethical issues (e.g., families who must consider end of life decisions for a loved one). Both rounds and care conferences have a leader.

Transitioning patient care to another health care provider involves risks

due to a lack of uniformity in the hand-off process and inadequate training on how to communicate during care transfer. Staff may not fully realize the importance of the specific patient information needed in the care transition process

ANTICipate Model

endorsed by the Agency for Healthcare Research and Quality (AHRQ). administrative data (A) must be accurate, new clinical information (N) must be updated, tasks (T) performed by the provider must be clearly explained, illness (I) severity must be communicated, and contingency plans (C) for changes in clinical status must be outlined to assist cross-coverage of the patient overnight

Incident Report

a document, usually confidential, describing any accident or deviation from policies or orders involving a patient, employee, or visitor on the premises of a health care facility.

Change of shift report usually involves

a smaller number of caregivers, rounds may include numerous providers.

Examples of key patient information included on the "ticket-to-ride"

allergies, fall risk, special considerations, oxygen requirements, and positioning needs.

Rounds

are often associated with information exchange by health care providers, interdisciplinary care teams, and specialized unit-based teams (e.g., a nurse skin care team).

Sentinel events

are often linked to communication problems. A sentinel event is an unexpected occurrence involving death, serious physical or psychological injury, or the risk of injury signal the need for an immediate investigation and response

EHRs

supports the development of standardized and integrated shift reports to facilitate better communication of significant information. When documentation is completed electronically at the point of care, the potential for miscommunications and omitted information is decreased.

When successfully implemented, bedside reporting is seen as

"providing a real-time exchange of information that increases patient safety, improves quality of care, increases accountability, and strengthens teamwork"

SBAR is used

"to report to a health care provider a situation that requires immediate action; to define the elements of a hand-off of a patient from one caregiver to another, such as during transfers from one unit to another or during shift report; and in quality improvement reports"

Ticket-to-ride Communication Tool

that includes important information to ensure appropriate care during transport and at the destination. Use of this tool decreases the risk of adverse events or errors while increasing patient satisfaction

In 2005, the World Health Organization published WHO Draft Guidelines for Adverse Event Reporting and Learning Systems to promote

the development and management of effective incident reporting systems

Nurses should:

Be affirmative about having the staff who "round" on their patients actually include their patients and their families (e.g., enter the room to speak with the patient; plan to be present when the family arrives). Encourage patients to actively participate in any information exchange that occurs about them. Ask patients to validate or confirm the information that is being discussed about them. Encourage patients to ask questions.

ANTICipate elements: Tasks to be performed

Clear explanation of tasks

Hand-off reporting serves many purposes:

Hand-off reports provide accurate and timely information about the care, treatment, and services rendered to a patient, addressing the patient's current condition and anticipated changes. Hand-off is a time when important information that is anchored in the nursing process is shared—assessment, planning, intervention, and evaluation. Patient information that supports care delivery and clinical decision making is discussed to facilitate continuity of care. The hand-off process can be an opportunity for collaborative problem solving. Hand-off includes the transfer of authority and responsibility for the patient's care Improvement in the hand-off process can increase patient safety and promote positive patient outcomes.

ANTICipate elements: Illness severity

Information about illness severity

WHO draft guidelines: Meaningful Learning

Meaningful analysis, learning, and dissemination of lessons learned requires expertise and other human and financial resources. The agency that receives reports must be capable of disseminating information, making recommendations for changes, and informing the development of solutions

Examples of instances in which an incident report should be completed:

Medication Error: a patient is given the incorrect dose of an analgesic Patient Fall: a child falls out of a hospital bed Equipment Malfunction: the cable of a powered bed sparks and starts to smoke Staff Injury: a patient knocks over an IV pole, which strikes a nurse on the head

ANTICipate elements: Administrative Data

Name, record number, location

Results of the Pilot Hand-Off Program

Nurses had increased knowledge about the priorities of their patients. Nurses who had recently graduated described increased feelings empowerment. Nurses who participated in the hand-off were able to jointly provide patient and family education and could partner to assess patients. Nurses perceived that the information exchange was appropriate and that relationships between staff working on different shifts improved. Patient satisfaction scores improved significantly in all three categories measured: Nurses kept patients informed Friendliness and courtesy of the staff Likelihood to recommend the hospital

The core principles underlying the WHO Draft Guidelines are:

Patient safety Safe reporting Constructive response Meaningful learning

ANTICipate elements: Contingency

Plans for changes in clinical status

ANTICipate elements: New clinical information to be updated

Real-time information

WHO draft guidelines: Constructive response

Reporting is only of value if it leads to a constructive response. At a minimum, this entails feedback of findings from data analysis. Ideally, it also includes recommendations for changes in processes and systems of health care.

WHO draft guidelines: Safe reporting

Reporting must be safe. Individuals who report incidents must not be punished or suffer other ill-effects from reporting.

WHO draft guidelines: Patient safety

The fundamental role of patient safety reporting systems is to enhance patient safety by learning from failures of the health care system.

Pilot Hand-Off Program

The hospital system implemented an evidence-based hand-off process that occurred at the bedside. A standardized tool was used by nurses exchanging information in the hand-off report to ensure that pertinent information was passed on to the staff on the next shift. Patients and their families were invited in writing to participate in the change-of-shift hand-off process. Patients and their families were the focus of the hand-off process. Nurses were purposeful about eliciting input from them.

Hand off

is a term that is typically used to describe the process of information exchange about a patient. may be written or verbal on the phone, in person, digitally, recorded at change of shift or change of unit for nurses and health care providers can occur between persons of the same discipline and between persons of different disciplines UAP may participate in the hand-off process with a nurse partner sharing information about a patient

The premise of incident reporting

is that reporting and investigation of unusual events, such as medication errors, accidents, and incidents that do not reach the patient (also known as near misses) can yield insight into weaknesses and opportunities for procedural improvement within a health care system.

Purpose of incident report

is to document the details of the incident immediately to ensure accuracy and to begin the process of an investigation.

SBAR

situation, background, assessment, and recommendation). Originally a situation-briefing tool used by the U.S. Navy, SBAR was adapted for health care at Kaiser Permanente of Colorado and is currently used in many facilities in the United States and in the British National Health Service.

Incident reports should be

objective, nonjudgmental, factual reports of the unusual occurrence and its consequences. The incident report is not part of a medical record, but is considered a risk management or quality-improvement document.

According to the Institute for Healthcare Improvement (2014), "SBAR

offers a simple way to help standardize communication and allows parties to have common expectations related to what is to be communicated and how the communication is structured".

Fear of blame and punishment in incidence reporting

often deter health care professionals from reporting incidents. Over the last decade, policies and procedures related to incident reporting have changed to become more blame-free. Incident reporting is encouraged, and investigations are sometimes referred to as "fact finding" so as not to connote punitive action.

Risks in handoff

risk for information omission or miscommunication ineffective hand-off may lead to wrong treatments, wrong medication, or other life-threatening events increasing the length of stay and causing patient injury or death