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Communication Error in Nurse to Nurse Patient Handover

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Marissa Mar

on 18 March 2014

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Transcript of Communication Error in Nurse to Nurse Patient Handover

Cultural Issues
Fraser Health is culturally diverse
May have cultural differences in communication styles (verbal/nonverbal)
Language barriers

External Factors
Availability of funding
Unusual massive influx of patients
Other Health Promotion Programs
Program Implementation - Time/Seasonality

Ensuring buy-in
top-down approach, existing approaches, awareness from other departments
Consistency into the future (enforcement), training for new nurses
Program Evaluation
Evaluating IMPACTS
Number of departments that adopt program/ Total number of applicable departments
Indicator Measured Through Time Allocation Interviews and Surveys
Organizational Culture variability of Health Authority and Emergency Department
Is report time = social time?
Department's capacity for tolerating change and desire to change (buy-in)
Staff comfort level with previous reporting systems (push back)

Aisha, Flora, Michelle, Marissa, Ian, & Andre
The Problem
Program Description
Communication Error in Nurse to Nurse Patient Handover
Program Evaluation
Evaluating INPUTS
Key Aspect to Evaluate:

Are adequate numbers of staff being recruited to both develop and deliver the program?

Number of RN's Involved in the Development and/or Delivery of the Program / Total Estimated Number of RN's Required to Effectively Run the Program
Indicator Measured through Observation & Record Review
(Estimated Required Numbers as Determined by Fraser Health & Program Management)
Program Evaluation
Program Evaluation
Evaluating OUTPUTS
Key Aspect to Evaluate:
Was an effective standardized reporting style developed, that addresses all or most of the areas of concern identified by RN focus groups?
Why it Matters
Errors in communication result in adverse events

Patient Handover:
process of handing over a patient’s information and responsibility for a patient from one health care provider to another
The Problem

Average Number of RN's Who Feel the Standardized Reporting Style Developed Addresses the Important Communication Concerns &
Feel the Standardization is Helpful in Patient Handovers
Indicators Measured through Interviews & Surveys
Key Aspect to Evaluate:
Did a sufficient percentage of RN's receive training on the new standardized reporting style, to warrant a positive change in handover errors?
Number of RN's Who Received Training /
Total Number of ER RN's in Fraser Health
Indicators Measured through Observation & Record Review, by Fraser Health & Program Management
Key Aspect to Evaluate:
Adoption of program throughout all departments in Fraser Health (not just ERs)

Program Evaluation
Evaluating OUTCOMES
Key Aspect to Evaluate:
How effectively are nurses communicating after program implementation?
Nurse Performance in Handover Communication After Program/ Nurse Performance in Handover Communication Before Program
Indicators Measured Through Self Evaluation Tool and Program Management Observation
Intervention Framework #1:

Implement Standardized Reporting
a) Accreditation Canada Requirement
Required Organizational Practice (ROP)
b) Feasibility
Changing Human Behavior

Our Goal:
Errors can be reduced by:
i) Increasing the accuracy of critical information exchange
ii) Increase retention of critical information received

How do we implement standardized reporting?

1) Use International (WHO) and National (Accreditation Canada) Best Practice Recommendations

2) Include input from nursing advisory and focus groups

3) Develop and Implement a standardized framework for patient handover communication
How do we implement standardized reporting?
3) Verbal & Written Reporting

face to face, uninterrupted communication
Allocate space and time
Use pre-printed patient forms
Repeat/Read Back Protocol
Question, Answer, Verification Period
Use standard forms for critical information
(i.e Kardex and SBAR techniques)
Program Description
Intervention Framework #2:
Training and Education Sessions

Our Goal:

Majority of health professionals are on the same page when important information is being shared.

Increase staff buy-in
Eliminate human factors during handover

Part of Project implementation process
A fixed item in new staff orientation

Our Focus
Nurse to nurse (RN) handovers in the ERs of Fraser Health
Program Description
What is "handed over"?
How does a handover occur?
Lack of record
Full transcript