Hand off Reporting and Incident Reporting-Unit 2

SBAR

A communication format that is specifically suggested for use in nurse-health care provider interactions and is used widely between all types of providers is SBAR (i.e., situation, background, assessment, and recommendation).

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 (The Joint Commission, 2014c). These events are called sentinel because they signal the need for an immediate investigation and response.

patient care conferences

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.

Ticket-to-ride communication tool

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

More about hand offs:

Depending on the clinical setting, a hand-off may be written or verbal. It may take place over the telephone, in person, digitally, or in some cases, through a recording. Hand-off usually involves patient information exchange at change of shift or change of unit (e.g., intensive care unit nurse to acute care floor nurse). Hand-off occurs between individuals who care for patients, such as nurses and health care providers. Hand-off may occur both between persons of the same discipline and between persons of different disciplines. Non-licensed assistive personnel may participate in the hand-off process with a nurse partner. Hand-off can include the sharing of information about a patient between a provider and staff at another center (e.g., upon patient discharge to an interim care facility).

ANTICipate Model. The ANTICipate model is endorsed by the Agency for Healthcare Research and Quality (AHRQ).

For a safe and effective hand-off using this model, 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

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 (AHRQ, 2008). Improvement in the hand-off process can increase patient safety and promote positive patient outcomes.

result of the 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

Which statements about bedside reporting are true?

Research suggests that bedside reporting increases patient safety and strengthens teamwork. Bedside reporting includes the patient and family. Nurses from the prior and oncoming shift must be physically present to view the patient.

What does SBAR stand for?

Situation, Background, Assessment, and Recommendation

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.

What are potential consequences of ineffectual or inaccurate hand-offs?

The patient may not get needed care. The risk of medication error may be increased. Errors in patient care may lead to patient injury or death.

tasks to be performed

clear explanation of tasks

bedside reporting

hand-off reporting done in the patient's room using a standardized format that includes the patient and the family. Nurses on the prior shift and the oncoming shift must be physically present to view the patient (e.g., incisions, medication infusion rates, skin color) and dialogue with patients who are able to communicate (e.g. discuss pain goals).

illness severity

information about illness severity

Hand-off

is a term that is typically used to describe the process of information exchange about a patient

Administrative data

name, record number, location

contingency

plans for changes in clinical status

new clinical information to be updated

real-time information