This is equivalent to 1 in every 100 admissions. Direct attending-physician-to-attending-physician communication was also suggested as a vehicle to address these knowledge and experience gaps. Use Bedside Reports With bedside reports, the nurse reports off to the nurse who will assume the patient's care during the change of shift at the patient's bedside. A service of the National Library of Medicine, National Institutes of Health. These were followed by standardization and protocol implementation, which combined, represented more than half of the suggestions.
This article introduces behaviours that support communication, co-operation and co-ordination in teams. Communication among clinicians in providing health care is a highly complex but important function in the delivery of health care. Including information, knowledge, and the pespective of all team members represents an important safety challenge that was commonly expressed as potentially a significant safety solution. Background The burden of harm from patient safety events pervades the health care system and is directly and indirectly experienced by many health care consumers. Number of focus group participants by clinician type. The tool matched expectations between senders caregivers who transmit patient data and transfer care and receivers caregivers who accept patient data and care.
No participant names were recorded; participants identified themselves by using a colored card to indicate when they were speaking e. See sidebar to download a sample of Good Samaritan's one-onone meeting form. Department of Defense Patient Safety Program, provides 10 sample patient handoff tools gathered from organizations around the country. The iPad application helps healthcare providers with patient information sharing. Clinicians have important contributions to make to inform interventions for patient safety improvement and the redesign of safer health care.
Cell phones were suggested as a potential tool to establish a clinical case conference by enabling several clinicians to be brought together over the phone for remote case conferences, which would facilitate communication among the clinicians caring for patients who have multiple services involved in their care. Additions included staff organization, risk assessment, learning from errors, and personal initiative. Lamkin Background: Teamwork and good communication are essential to providing high-quality care. Smith had pain medication about 15 minutes ago, but she's not comfortable yet. Clinicians describe multiple communication problems and patient safety risks that would be addressed specifically by organizing medical information in such a manner to systematically provide easily accessible summary lists of all orders, labs, and consults with contact information for the consults. Such a consortium is necessary in order to have a sufficiently large and varied population of pediatric patients for research findings to be generalizable, to provide information about different pediatric health care settings e.
Classification of all data into the developed categories. The Safer Sign Out protocol, developed by the Emergency Medicine Patient Safety Foundation, aims to improve the safety and reliability of end-of-shift patient handoffs. It also reduces medication errors and miscommunication about the patient's condition. The Chicago Pediatric Patient Safety Consortium The Chicago Pediatric Patient Safety Consortium Peds Consortium was established to conduct research concerning pediatric patient safety. The software includes a secure physician case list, real-time patient handoff capabilities, team instant messaging and a clinical article editor. Data Collection To examine clinician experience related to pediatric patient safety, a series of focus groups was conducted at each site. A review of the transcript of recommended solutions revealed three transcript exerpts that were workarounds, done to cope rather than address the safety problem.
Furthermore, resident physicians must receive training in pediatric health care, but these resident physicians have had minimal or no previous pediatric training. It delivers real-time data to clinicians and allows nurses to re-prioritize their tasks quickly to manage new challenges and issues. Clinicians suggested the inclusion of pharmacists and nutritionists into interdisciplinary rounds to address particular patient safety risks in pediatrics. In this article, we focus specifically on the potential patient safety solutions clinicians recommended. Advances in Patient Safety: New Directions and Alternative Approaches Vol. Recommended Types of Safety Solutions shows the types of interventions recommended to address specific patient safety-related communication problems and the number of times, across all of the focus groups, that these solutions were recommended. The pocket card was developed by University of Chicago Medical Center.
Problematic processes and systems for clinician communication have been shown to lead to patient safety risk for children as well as for adults. Sprague Memorial Institute and the Chicago Patient Safety Forum, an initiative of the Institute of Medicine of Chicago in the development of the Peds Consortium. Clinicians frequently offered solutions to the problematic communication contexts, processes, and systems they described. Data collection for this study consisted of focus groups that comprised hospital-based attending physicians, residents, nurses, and pharmacists; transport teams; and respiratory therapists currently involved in the delivery of pediatric patient care in one of the five Peds Consortium hospitals. Focus groups included 2 to 11 participating clinicians, with a mean of 4. Pediatric care involves caring for children of varying ages and stages with varying normal ranges of clinical values and test results and care processes and priorities. Finally, clinicians ascribed the responsibility for institutional learning from errors to leadership and suggested that cross-departmental, multidisciplinary contexts for learning about errors as a potentially meaningful approach.
The recommendation to add advanced practice nurses or hospitalists to the clinical team to provide pediatric-specific medical knowledge and coordination was also common. We convened focus groups within each discipline e. Recruitment included a presentation of the project in departmental and unit meetings and a letter sent to selected clinicians. These were refined through review by the remaining Peds Consortium investigators Steps 4—6. The tools include forms, posters, worksheets and a button design.
Coding of focus group transcripts resulted in the identification of 252 clinician-recommended solutions to address the patient safety-related communication problems described in the provision of health care. Hospital of Cook County Dr. This resulted in 249 clinician-recommended solutions for analysis. Cell phones and text pagers were described as having the additional advantage of providing verification of the receipt of information, developing expectations for the initiator of the response, and in the case of cell phone, providing the ability to ask on-the-spot questions, clarify issues, and develop a plan. Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes.