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Transcript

Hand Off Communication - SBAR

GMHHC

2017

Objectives

SUMMARY

  • List and define SBAR
  • 3 reasons why SBAR is important to use
  • How SBAR affects patient safety

Situation

Background

Assessment

Recommendation

FOCUS

AREA

1

What is SBAR?

  • The SBAR model is a simple method to help standardize communication

  • SBAR allows all parties to have common expectations:
  • What is going to be communicated
  • How the communication is structured
  • Required elements

  • Focuses on the problem, not the people

THE PROBLEM

Contributing Factors

  • Inadequate hand-off communication is a contributing factor to adverse events
  • The Joint Commission's sentinel event database includes reports of inadequate hand-off communication causing:
  • Wrong-site surgery
  • Delay in treatment
  • Falls
  • Medication errors
  • Study in 2016 estimated 30% of malpractice claims were due to communication failures in US hospitals
  • Resulting in: 1,744 deaths and $1.7 billion in malpractice costs over 5 years

IMPORTANCE

Why it's important to use

  • According to the Joint Commission, communication issues are the leading cause of sentinel events in hospitals.
  • The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first.”
  • The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. (https://www.ncbi.nlm.nih.gov/books/NBK2649/)

TOOL

SBAR tool that should be used

Case Study #1

2

FOCUS

AREA

SUCCESSFUL

Assessment

Situation

Patient is 25 years old. She is 32 weeks, complaining of cramping and bloody show. She is a G8 P4.

Patient is on the monitor showing contractions 2-3 minutes apart. Vitals are stable. Fetal heart monitor times 140 with a Category 1 tracing. She is Nitrazine positive and dilated 6 cm 0 station.

Recommendations

Background

Patient has had 2 previous preterm births at 32-34 weeks. She has not had prenatal care

Admit the patient to labor. Draw labs. Do a drug screening. Get a stat ultrasound. Have NICU on standby.

Results

Doctor makes the birth.

FAILED

Situation

Assessment

Nurse calls OB to inform doctor of the situation

Patient is 25 years old. She is 32 weeks complaining of cramping and bloody show.

Recommendation

Background

Patient has had 2 previous births.

OB states he/she is coming in.

Results

Doctor misses the birth due failed communication.

TIPS

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