Title: Communication
1Communication
- Linda Ferris
- Hilton Hotel
- 15th November 2007
2- Communication breakdowns between health care
providers are a central feature in episodes of
avoidable patient harm
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4Inter-Professional Communication
5Scenario 1
6Mortality Diagnostic Casenote Review
- Failure to Plan (Diagnosis / Treatment)
- Failure to Identify changes in the patients
clinical indicators. (Heart Rate, Respirations,
B/P, SPO2)
- Failure to Communicate (between doctors and
nurses, team, no clear lead physician) - Failure to Rescue or Respond to changes in the
patients clinical indicators.
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8ALERT
- Acute
- Life threatening
- Events
- Recognition and
- Treatment
9Scenario 2
10SBAR
11The SBAR (Situation-Background-Assessment-Recommen
dation) technique provides a framework for
communication between members of the health care
team about a patient's condition. SBAR is an
easy-to-remember, concrete mechanism useful for
framing any conversation, especially critical
ones, requiring a clinicians immediate attention
and action. It allows for an easy and focused way
to set expectations for what will be communicated
and how between members of the team, which is
essential for developing teamwork and fostering a
culture of patient safety.
12SBAR
13SBAR,
- is based on techniques developed in commercial
aviation. Co-pilots were having a difficult time
communicating clearly to pilots, in situations
where there was potential danger, in part because
the power gradient between them was so high.
There are many examples of black box recordings
found after airplane accidents, where the
co-pilots were using the hint and hope
approach, even as the plane was about to crash.
14SBAR
- Assessment
- Recommendation
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17Scenario 3
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19Safety Briefing
- Safety briefings are an integral part of
developing a culture of safety. They are used to
increase staff awareness of safety issues,
creating an environment in which staff share
information without fear of reprisal and
integrate the reporting of safety issues into
their daily work. - Convene at least one safety briefing each day.
20Safety Briefing
- One of the keys to success is to make sure that
information generated at the briefing session is
passed on to the next shift. - Briefing should last 5-10 minutes
- Topics should include, patients, equipment,
staffing, infection control.
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22Nursing Handover
- Because clinical teamwork often involves hurried
interactions between human beings with varying
styles of communication, a standardized approach
to information sharing is needed to ensure that
patient information is consistently and
accurately imparted. This is especially true
during critical events, shift handovers, or
patient transfers.
23NURSING HANDOVER
24Thank You