sábado, 4 de abril de 2015

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web: Improving Communication Between Clinicians

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

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The dynamic environment in which health care is delivered requires clinicians to maintain situational awareness. The concept of situational awareness refers to the ability to access and track data relevant to the task at hand, comprehend the data, forecast what may happen based on the data, and formulate an appropriate plan in response. In a clinical context, maintaining situational awareness requires information sharing and open dialogue among clinicians in order to achieve a shared mental model—the "big picture" of the patient's condition and immediate priorities for care.

Situational awareness cannot be achieved without clear and high-quality communication between all of the providers who are caring for a patient. For example, if a patient on a medical ward begins to deteriorate, the bedside nurse will need to communicate information about the patient's known diagnoses, symptoms, vital signs, and acuity in a clear and timely fashion to the responding clinician who, in turn, will need to respond respectfully, process and comprehend the new information, and devise a plan. Any breakdown in this chain of communication will lead to impaired situational awareness, and patients may be harmed as a result. An AHRQ WebM&M casedetails the death of an infant shortly after repair of a congenital heart defect. Both the intensive care unit team and the cardiac surgery team were aware of the patient's deteriorating condition, but each assumed the other was primarily managing the problem. Poor communication between the two teams meant the severity of the patient's condition was not appreciated until it was too late.

Unfortunately, problems with communication between clinicians are pervasive and clearly result in preventable patient harm. Seminal studies have shown that poor levels of communication exist between clinicians at all levels of the health care system. The Joint Commission has found that communication issues are the most common root cause of sentinel events (serious and preventable patient harm incidents). In the operating room, poor communication has been directly linked to surgical complications and has also been implicated in malpractice lawsuits in multiple clinical settings.

This Patient Safety Primer will discuss methods of improving communication between clinicians in the context of routine patient care and emergency situations. Issues involving communication between clinicians at times of transitions in care are discussed in the Handoffs and SignoutsAdverse Events after Hospital Discharge, andChecklists Patient Safety Primers.

Methods of Improving Communication Between Providers

The factors that impair effective communication between providers often relate to cultural norms and expectations within the health care environment. Rigid hierarchies, in which authority gradients discourage frontline workers from raising concerns with leadership, are persistent within health care and a known contributor to preventable harm. Overtly disruptive and unprofessional behavior is less common, but has a chilling effect on communication and teamwork. More subtle issues, such as nonverbal cues, interpersonal relations, and group dynamics, can affect communication in ways that may not be readily apparent, even to the parties involved. In many ways, these factors contribute to the overall culture of safety within an organization.

Approaches to improving communication between clinicians share common goals, but differ depending on the context. Efforts to enhance communication in the course of routine patient care have focused on developing standardized communication protocols for transmission of important information. For example, read-back protocols are now standard practice for communication of critical test results in order to reduce errors of omission. TheSituation-Background-Assessment-Recommendation (SBAR) approach is widely used to facilitate communication between nurses and physicians by offering a standardized way of communicating the clinical assessment of a patient requiring acute attention. Used correctly, SBAR can be an effective tool to minimize authority gradients.

At the health care system level, formal teamwork training programs explicitly focus on enhancing communication behaviors within teams, and a growing body of literature demonstrates that improved team behaviors lead to better patient outcomes. The unit-based safety team model, which emphasizes teamwork training approaches within a geographic unit, has also been effective in improving safety culture. Organizations are also taking a more proactive stance in addressing disruptive and unprofessional behavior by clinicians at all levels.

Current Context

The Joint Commission includes "improving staff communication" as one of its National Patient Safety Goals, emphasizing the importance of communicating test results accurately. The National Quality Forum also includes multiple approaches to enhancing communication as part of the Safe Practices for Better Healthcare.
What's New in Improving Communication Between Clinicians on AHRQ PSNet
Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015.
Bridging the gap between hospital and primary care: the pharmacist home visit.
Ensing HT, Koster ES, Stuijt CCM, van Dooren AA, Bouvy ML. Int J Clin Pharm. 2015 Mar 11; [Epub ahead of print].
Targeted communication intervention using nursing crew resource management principles.
Tschannen D, McClish D, Aebersold M, Rohde JM. J Nurs Care Qual. 2015;30:7-11.
Middle East Forum on Quality and Safety in Healthcare.
Hamad Medical Corporation and Institute for Healthcare Improvement. May 29–31, 2015; QNCC, Doha, Qatar.
Injection Safety.
World Health Organization.
Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home.
Labson MC. Home Healthc Now. 2015;33:142-146.
FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
Editor's Picks for Improving Communication Between Clinicians

Communication Failure—Who's in Charge?
Jim Fackler, MD, and Jamie M. Schwartz, MD. AHRQ WebM&M [serial online]. October 2011
Intubation Mishap.
Matthew B. Weinger, MD; George T. Blike, MD. AHRQ WebM&M [serial online]. September 2003
Providers' perceptions of communication breakdowns in cancer care.
Prouty CD, Mazor KM, Greene SM, et al. J Gen Intern Med. 2014;29:1122-1130.
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.
Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2012;22:118-126.
Unit-based care teams and the frequency and quality of physician–nurse communications.
Gordon MB, Melvin P, Graham D, et al. Arch Pediatr Adolesc Med. 2011;165:424-428.
 Classic iconSurgical team behaviors and patient outcomes.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.
 Classic iconPatterns of communication breakdowns resulting in injury to surgical patients.
Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.
 Classic iconCommunication failures: an insidious contributor to medical mishaps.
Sutcliffe KM, Lewton E, Rosenthal MM. Acad Med. 2004;79:186-194.
 Classic iconCommunication failures in the operating room: an observational classification of recurrent types and effects.
Lingard L, Espin S, Whyte S, et al. Qual Saf Health Care. 2004;13:330-334.

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