mod 3 ch 26 hand off and incident reporting Flashcards
hand off
describe process data and information exchange about pt
- written or verbal
- over phone, person, digital, recording
- usually btw shifts or transfer pt
- btw indivs caring for pt
- may btw interdisciplinary exchanges
- sharing pt info btw hcp and staff another facility
** unlicensed assistive personnel may participate in hand off with nurse partner
purpose hand off
ensure pt safety through provision of accurate, up-to-date data and info and transfer pt care responsibilities
- provide accurate and timely info about care, tx, and services, pt current cond and anticipated changes
- time for important info shared: assessment, planning, intervention, evaluation
- facilitates continuity care’opp for collaborative tm approach to problem solving
- transfer authority and responsibility
- increase pt safety and promote fav pt outcomes
methods hand offs
SBAR - prompt and appr comms, uses nursing process including active situation, related background, problem assessment, and recommendation for solution
I-PASS
I - illness severity- standard 1 word description
P - pt summary- brief summary tx plan and diagnosis
A - action list- what hcp needs to do when receiving pt
S - situational awareness and contingency plans-
S - synthesis by receiver- provides time for receiver to ask questions and confirm care
ANTICipate
A- administrative data must be accurate
N- new clinical info up to date
T- tasks performed by hcp clearly explained
I- illness severity communicated
C- contingency plans for changes in status documented
sentinel event
unexpected occurrence involving death, permenant harm, or severe temp harm - signal need for immediate investigation and response
Types:
death, suicide, wrong site, procedure or pt, chronic or fatal disease trans from blood trans, infant abduction
communication problems
- insufficient handoff 30% malpractice
- tx delays and med errors
- evidence-based frameworks used to overcome errors
reduction of sentinel events
- standardization critical data and info
- face-to-face comms
- use info tech for add to support
- monitor tm support and effectiveness processes to increase evidence and sustain best practices
Which description best characterizes the hand-off process?
Transfer and acceptance of patient responsibility
Accurate and complete hand-offs are essential for patient safety and quality of care. A hand-off transfers patient responsibility from one caregiver to another through the presentation of accurate and up-to-date patient information.
Which is an accurate representation of all elements contained in “SBAR?”
Situation, Background, Assessment, and Recommendation
Which components comprise the I-PASS hand-off process?
- id pt acuity (illness severity)
- time for receiving rn to ask questions (synthesis by receiver)
- Pt treatment plan (action last)
culture of safety
elements
- safe ops in high-risk nature of health care
- blame-free environment where learning exists
- cross-discipline collaboration for pt safety
- env of commitment to devel resources to support culture
reducing errors
- education- facility-wide and unit-based
- surveys- understanding safety practices
- benchmarks to compare effectiveness
Reducing blame
- tries to deter punishment for incidence reporting
reporting incidence
off documentation of facts of accident or injury-related incident and/or breach of practice or policy
2 types:
occurred or could had occurred (near miss)
what to do if incident occurs
staff injury
- location, date/time, chronology of event, eq involved, witnesses, injury detail and severity, disposition of injured
eq malfunction
- location, date/time, eq type, event description, injuries, level harm
pt fall
- location, date/time, unit, details, injury level
med error
pt name, outcome, labeling, written prescription, responsible person
incident report concepts
pt safety- enhance pt safety by learnign from failures
safe reporting- safety process not punitive, must be protected for reporting
constructive response- feedback and learning is essential for cultural safety, include recs for change
meaningful learning- dissemination is key, making recs for change
Which phrase describes the main purpose of completing an incident report?
Records details of an incident and begins the process of a quality improvement investigation
The purpose of completing an incident report is to document the details of the incident immediately to ensure accuracy and to begin the process of an investigation.
Which statements exemplify the core principles of incident reporting?
- incident reporting provides opp to learn from errors
- all indivs must be able report incident w/out blame
- incident reporting should result pos changes rel to pt care and safety
Match the documentation needs to the type of incident.
Patient name, outcome, labeling, written prescription, responsible person
—Medication error
Location, date and time, fall circumstances, injury level
—Patient fall
Location, date and time, event description, injuries, harm level
—Equipment malfunction
Date and time, chronology, witness names, injury severity, person disposition
—Staff injury
In which way can nurses perform effective hand-off reporting?
ensure complete and accurate info conveyed
