Class 6-Effective Communication and Patient Safety

Question 1

new standards for improved communication

Answer 1

ISBAR

Question 2

TJC definition of a sentinel event

Answer 2

a patient safety even (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:
-death
-permanent harm
-severe temporary harm

Question 3

severe temporary harm

Answer 3

-is critical, potentially life-threatening harm lasting for a limited time with no permanent residual
-usually involves being sent to a higher level (temporary)

Question 4

an event is also considered sentinel if it is one of the following “other events”

Answer 4

-suicide in a staffed setting or within 72 hours of discharge (including ED)..should have been picked up on
-unanticipated death of a full-term infant
-discharge of an infant to the wrong family
-abduction of any patient receiving services
-any elopement (leaving unsupervised; solid, teal gown)
-surgical souvenirs (left in pt’s body)
-falls resulting in harm
-administration of wrong blood (skipping steps; shortcuts)

Question 5

root cause analysis

Answer 5

> 70% of all sentinel events are a direct of communication failure

Question 6

top 10 sentinel events reviewed by TJC for 2022 by cause

Answer 6

-falls 611
-delay in treatment 89 (communication prob)
-unintended retention of a foreign object 88
-wrong surgery 85 (pt, surgery, wrong)
-suicides 73
-criminal event-assault/rape/sexual assault 60
-fire 49
-perinatal event 33
-self harm 30
-medication error 30

Question 7

sentinel event alert 52, 53

Answer 7

-#52: preventing infection from the misuse of vials (2014) (1 needle, 1 syringe, 1 vial, 1 time only)
-#53: managing risk during transition to new ISO (international standard organization) tubing connector standards (2014); tubes getting mixed up

Question 8

components of a safe culture

Answer 8

patient at center
-leadership
-human factors (stress; multi tasking; distractions)
-reliability (policies & procedures in place to protect me)

Question 9

common communication errors

Answer 9

direct communication errors
-presenting information in a disorganized manner
-speaking in ambiguous terms (up, down, good, bad don’t use)
-omitting information

-failure to plan
-failure to recognize
-failure to rescue

Question 10

pitfalls in our clinical settings

Answer 10

-operational pressures
-short cuts
-language barriers
-assumptions of safety
-complex unsafe systems
-stressful situations
-distractions & interruptions, multi-tasking
-limitations of human memory (write things down)
-fatigue

Question 11

why is assertion for nurses so hard?

Answer 11

power difference (doctor vs nurses)

Question 12

tools and behaviors for effective communication

Answer 12

-appropriate assertion
-ISBAR or IPASS
-critical language-CUS (concerned; unsafe)
-effective leadership

Question 13

ISBAR

Answer 13

-introduction of yourself
-situation: 5-10 seconds-why you picked phone up
-background:
-assessment: (hardest part; what you think is going on)
-recommendations:

Question 14

before I make the call

Answer 14

-assess the patient yourself
-discussed the situation with a resource person if necessary
-reviewed the chart
-know the admitting diagnosis
-read the most recent process notes
-have available the following:
-patient’s chart
-current meds, IV fluids, labs, ventilator settings
-most recent VS
-code status

Question 15

see slide 15 for ‘cheat sheet’

Question 16

see slide 16 for ISBAR example

Question 17

benefits of ISBAR communication

Answer 17

-improves patient safety
-promotes critical thinking (recognizing; analyzing cues)
-develops teamwork
-increased employee satisfaction (felt part of the team)

Question 18

I-PASS

Answer 18

-illness severity
-patient summary
-action list
-situation awareness and contingency planning
-synthesis of receiver (repeat back)

Question 19

look at slides 19 & 20