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Nurses are always concerned about keeping their patients safe. Besides doing so by being professional with caring directly for them, nurses also need to be aware of how communication—with other health care providers and patients—can either keep patients safe or put them at risk.
Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can do this.
In Part 1 of this series, we address what high-risk situations could be as well as how nurses can safely communicate with other health care providers. Part 2 will cover specific ways in which nurses can communicate with their patients while keeping them safe.
What is a high-risk situation and what kinds of patients could be involved in these?
High-risk clinical presentations occur throughout multiple areas of medical care. Medical errors in these critical situations can induce significant patient harm or even death. You might find a high-risk scenario:
- In the emergency department as you care for all comers presenting with a wide variety of complaints from back pain and chest pain to headaches and injuries to extremities
- In the ICU when caring for fragile patients with a life-threatening infection
- Before, during, or after a surgery
You might also encounter groups of patients that are inherently more high-risk. These include:
- Patients with multiple comorbidities
Effective communication between nurses and other clinical providers plays a vital role in the effective management of high-risk clinical situations. Unfortunately, traditional nursing and medical school programs do not include training in techniques to ensure successful communication in health care. As a result, a significant number of patients are harmed by breakdowns in communication.
What are the best ways for nurses to communicate with other providers to best keep their patients safe?
A study of over 23,000 malpractice claims by CRICO, the medical malpractice insurer of the Harvard medical institutions, revealed that “communication failures were linked to 1,744 deaths in five years.” The study also found 7,149 cases where communication breakdowns caused patient harm, and 26% of those breakdowns involved a miscommunication of the patient’s condition among providers.
One critical strategy to improve communication among providers is the use of the “read-back” method. In high-risk clinical situations, physicians often give verbal medication orders to nursing personnel. Such orders must be “read back” or “talked back” to the ordering physician or practitioner to confirm accuracy. This same technique should be utilized when receiving verbal lab and test results as well.
In one case, a nurse answered a telephone call from the lab with a patient’s biopsy test. The pathologist called in the result as being an “adenocarcinoma,” a type of malignant cancer. However, perhaps due to a poor phone line, the nurse thought the pathologist said the specimen “had no carcinoma.” A simple “read-back” would have avoided the error. “Doctor, did you say that the biopsy did not have a carcinoma?” The pathologist could then have then replied, “No, it is an adenocarcinoma which is malignant,” and the error would have been avoided.
Fortunately, there are a variety of simple techniques that nurses can employ to improve communication in clinical settings. It has long been known that nurses and physicians often describe the same patient situation in different ways. Nurses have been trained to give detailed, specific descriptions of a patient’s condition. Physicians, on the other hand, speak in bullets or quick lists of clinical findings. This mismatch in communication style can easily lead to misinterpretation and misunderstanding.
One simple method to overcome this communication barrier is the use of CUS – concerned, uncomfortable, and safety – to demonstrate an increasing severity of a patient’s condition. For example, if a postoperative patient is running an elevated temperature, the nurse could say, “Doctor, I am concerned about Mrs. Jones, as she has a temp of 102 degrees.” The next level of severity would be, “Doctor, I am uncomfortable with Mrs. Jones as she is spiking a temp to 103 degrees and is tachycardic.” As the condition worsens, the conversation might be, “Doctor, I am worried about the safety of Mrs. Jones. She is febrile, tachycardic, and complaining of severe abdominal pain.”
Many medical errors are caused by the reporting of incorrect or incomplete patient medical information during a handoff. Health care handoffs are an extremely common time in which communication mistakes occur. Fortunately, the health care industry now has access to easy-to-use handoff techniques. The SBAR method was originally created to ensure correct communication on nuclear submarines and has been adapted for health care use. The technique utilizes a handoff worksheet that is created by the sender of the clinical information, and then discussed with and handed off to the receiver of the information.
The simple mnemonic SBAR to be completed on the worksheet represents:
S – Situation: “What is going on with the patient?”
B – Background: “What is the clinical background or context?”
A – Assessment: “What do I think the problem is?”
R – Recommendations: “What would I do to correct it?”
Although the SBAR system is widely used today, some health care organizations are moving to a handoff technique that integrates the electronic medical record. One such method is I-PASS, in which the computer creates and prints out the handoff work sheet. The I-PASS worksheet mnemonic contains:
I – Illness severity
P – Patient summary
A – Action list for the next team
S – Situation awareness and contingency plans
S – Synthesis and “read-back”
Check out Part 2 for information regarding communication skills for nurses to safely speak with their patients.