Improving  Signout Skills Case-based workshop  Intern Orientation  Department of Medicine University of Chicago & Mercy Ho...
Goals <ul><li>Review common pitfalls during signout </li></ul><ul><ul><li>Environmental, cultural and communication barrie...
State of Current Signouts (n=34) % noting sometimes, often or always 65% Discovered overnight events that should have been...
Hand-off Theatre
What went well in this scenario? Observations Facilitators Other  Environmental  (e.g., distractions and obstacles interfe...
http://www.youtube.com/MergeLab#p/u/4/JzCdoQEYHkY
Debriefing <ul><li>What types of barriers to an effective hand-off did you observe? </li></ul><ul><ul><li>Environment </li...
Pre-handoff Arrival Dialogue Post-handoff Sender organizes & updates handoff information Stop patient care tasks to conduc...
Swiss Cheese Model Modified from Reason, 1991 © 1991, James Reason Triggers DEFENSES Accident Institution Organization Pro...
Two Way Street <ul><li>Best understood as a  dialogue  </li></ul><ul><ul><li>an interaction that fosters common ground, em...
Signout Skills Exercise
Mock Chart <ul><li>10 Minutes to Review H&P  </li></ul><ul><li>Look at the blank signout template and abstract any critica...
Interval Events Video <ul><li>Now we will watch a short video (<3 minute video) that will highlight the events of the day ...
http://web.me.com/johnparo/MedSchoolRock/oshe.html
Execute a Signout <ul><li>When you are ready, turn to your partner to execute the signout  </li></ul>
Hand-off CEX <ul><li>Receiver complete this evaluation on the sender </li></ul><ul><li>Domains assessed: </li></ul><ul><ul...
Volunteers <ul><li>Come up and demonstrate a handoff </li></ul>
How to  Execute a Signout
Core Components of Handoffs <ul><li>Verbal Communication </li></ul><ul><ul><li>In person or over phone </li></ul></ul><ul>...
Written Sign-out Review <ul><li>Constructing a written sign-out  </li></ul><ul><li>To abstract from H&P </li></ul><ul><ul>...
9 D’s  <ul><li>iDentity / Doctor / DNR or other directive? </li></ul><ul><li>Diagnosis & Diseases </li></ul><ul><li>Diet  ...
iDentitiy <ul><li>Room Number </li></ul><ul><li>First thing is location (7 th  vs 11 th  fl) </li></ul><ul><li>Patient Nam...
Diagnosis and Disease <ul><li>Can place under the same column </li></ul><ul><li>Diagnosis first  </li></ul><ul><li>It is t...
Drugs <ul><li>Sometimes difficult to list all of them </li></ul><ul><ul><li>Still possible </li></ul></ul><ul><ul><li>Can ...
Diet <ul><li>Many calls about NPO status  </li></ul><ul><li>Especially in patients going to surgery or procedures the next...
Daily Progress/Plan <ul><li>Things that explain patient’s CURRENT condition, progress, interventions,problems, plans. </li...
Directions <ul><li>Items To Do    Only important things that needs to be addressed or requires follow up </li></ul><ul><u...
Updating Written Sign-out  <ul><li>Update daily – need to build in time to do this! </li></ul><ul><ul><li>Drugs   </li></u...
Importance of Updating <ul><li>When comparing meds on sign-out to patient charts, nearly 1/3 discrepant  </li></ul><ul><ul...
A Word of Caution on Technology <ul><li>Computerized sign-out </li></ul><ul><ul><li>Brigham and Women’s Hospital  ( Peters...
Another Caution:  CoPaGA Syndrome <ul><li>CoPaGA = Copy Paste Gone Amok </li></ul><ul><li>Repeated highlighting, copying a...
TMI?  Information Overload <ul><li>Overreliance on signouts for your own work </li></ul><ul><ul><li>Signouts become unnece...
Improving Handoffs: How to Communicate Better Verbally “ who says what to whom in what channel with what effect”   Harold ...
Psychology of Miscommunication <ul><li>Speakers systematically overestimate how well their messages are understood by list...
Same Biases in Signout <ul><li>The most important piece of information was NOT communicated 60% of the time  </li></ul><ul...
So What Can Senders Do? <ul><li>Think about the  “R”eceiver (4Rs) </li></ul><ul><li>Relevant   items that will be  Remembe...
What Can Receivers Do? <ul><li>Actively listen </li></ul><ul><ul><li>stay focused, limit interruptions, taking notes can e...
Use of Read-Backs in Healthcare <ul><li>“ Read-back” </li></ul><ul><ul><li>Reduces errors in lab reporting </li></ul></ul>...
Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR?  OK, this is our sickest patient, and he’s ful...
Some Case Examples… Based on real signouts…
A nurse calls because the patient wants to know if they can eat.  Signout says “Patient is NPO for surgery tomorrow” Alway...
Your signout says  “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? Wha...
A patient you are covering is being evaluated for small bowel obstruction.  The attending surgeon comes by after being in ...
 
 
EXTRA SLIDES
Case of SBAR <ul><li>Originated in Navy to communicate critical situations </li></ul><ul><li>Adapted for nurse to physicia...
Misuse of SBAR <ul><li>Using “SBAR” as a verb </li></ul><ul><ul><li>“ I’m SBARing”  </li></ul></ul><ul><li>Failing to cust...
SBAR Arora, Johnson, Jt Comm J Qual Patient Saf. Schilling, eds. 2009
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Sign-out Workshop for New Interns

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Skills-based sign-out workshop that focuses on teaching interns and students how to create and update a written sign-out and how to perform a verbal handover. Used at orientations for interns or sub-interns.

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  • We concluded that despite these limitations, it is important to note that more than a quarter of medication entries were discrepant when comparing the sign-out to the chart, and that the majority of these medication omissions and comissions were not trivial, but instead had the “potential to cause moderate or severe clinical deterioration.” Specifically, omissions were more common, but comissions were more serious. 80% of daily sign-outs for a patient contained at least 1 medication omission, of which majority potentially harmful nearly 40% contained at least 1 commission
  • Now lets turn to communication in healthcare…what do we know…first we know that it is indispensible. This is important particularly in the context of future IT solutions which are sometimes touted as the safer. **** Refs: Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):121-4. Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322(7294):1101-3. The results from 1443/3228 (45%) of urgent requests from accident and emergency and 529/1836 (29%) from the admissions ward were never accessed via the ward terminal. Results from 794/3228 (25%) of accident and emergency requests and 413/1836 (22%) of admissions ward requests were seen within 1 hour of becoming available while a further 491/3228 (15%) and 341/1836 (19%) respectively were accessed between 1 and 3 hours. In up to 43/1443 (3%) of the accident and emergency test results that were never looked at the findings might have led to an immediate change in patient management. CONCLUSIONS: When used as the sole substitute for telephoning results, the provision of terminal access to laboratory results on wards can hinder rather than promote the communication of emergency blood results to healthcare staff.
  • First, studies show that speakers systematically overestimate how well their messages are understood by listeners.15 Secondly, the more knowledge that people share, the worse they communicate new material because they overestimate the knowledge of the other.16 Such general psychological processes could systematically impact the effectiveness of communication during hand-offs. If this is true, then post-call interns should overestimate the effectiveness of their communication.
  • Interviewed incoming and outgoing pediatric interns 1 h after handoff over 6 months Asked senders to guess what receivers would say was the most important information for each patient (had access to signouts)
  • But the good news, is that communication can be improved, and that is one goal of today’s workshop. In fact, more structured communication, such as the use of a read-back, similar to your neighborhood drive-thru that confirms your order, reduces errors during telephone reporting of abnormal lab values. Highlight that 4 people refused to read back the message - &gt; importance of institutional culture **** Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121(6):801-3. The recipients were asked to repeat the name of the patient, the test, and the result; the technologists noted this on the form. In addition, they noted the time necessary for the entire phone call and the extra time necessary to ask for the message to be repeated and for it to be repeated. Data $11.25/hour ($0.19/minute or $0.0032/second), the extra time to repeat the message costs the hospital from $0.11 to $0.16 per call ($0.07 per 13 seconds for a laboratory technologist’s time plus $0.04-$0.09 per 13 seconds for the recipient’s time).
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • Sign-out Workshop for New Interns

    1. 1. Improving Signout Skills Case-based workshop Intern Orientation Department of Medicine University of Chicago & Mercy Hospital
    2. 2. Goals <ul><li>Review common pitfalls during signout </li></ul><ul><ul><li>Environmental, cultural and communication barriers </li></ul></ul><ul><li>Learn </li></ul><ul><ul><li>To create and update a written signout </li></ul></ul><ul><ul><li>How to execute a verbal handoff using effective communication strategies </li></ul></ul>
    3. 3. State of Current Signouts (n=34) % noting sometimes, often or always 65% Discovered overnight events that should have been verbally communicated at sign-in 59% Overnight events documented 59% How often do you get morning signout 55% Reporting errors during signout 69% Missed content on signout sheet 72% Uncertain about medical decisions 84% Discovered events should have been notified
    4. 4. Hand-off Theatre
    5. 5. What went well in this scenario? Observations Facilitators Other Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Observations/Thoughts Barriers
    6. 6. http://www.youtube.com/MergeLab#p/u/4/JzCdoQEYHkY
    7. 7. Debriefing <ul><li>What types of barriers to an effective hand-off did you observe? </li></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Cultural </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Any others? </li></ul></ul>
    8. 8. Pre-handoff Arrival Dialogue Post-handoff Sender organizes & updates handoff information Stop patient care tasks to conduct handoff Specific verbal exchange between sender and receiver (could be in person or over phone) Receiver integrates new information and assumes care of patient(s) <ul><li>Lack of time, poor time management, fatigue, or work prevent updating </li></ul><ul><li>Lack of clinical judgment to construct proper handoff </li></ul><ul><li>Vague language </li></ul><ul><li>No set location or time </li></ul><ul><li>Not able to contact sender or receiver </li></ul><ul><li>Competing obligations (work or personal) </li></ul><ul><li>Handoff not a priority over tasks </li></ul><ul><li>Sender could </li></ul><ul><li>Provide disorganized info </li></ul><ul><li>Use vague or unclear language </li></ul><ul><li>Fail to provide clinical impression (what is wrong), anticipatory guidance (if/then), plan (to do), & rationale (why) </li></ul><ul><li>Receiver could </li></ul><ul><li>Not listen (distractions) </li></ul><ul><li>Misunderstand </li></ul><ul><li>Not clarify (ask questions) </li></ul><ul><li>Forget key tasks or information </li></ul><ul><li>Not document actions taken </li></ul><ul><li>Act on plan without taking new arriving information into account </li></ul><ul><li>Not invest in the care of patient (lack of professional responsibility) </li></ul>
    9. 9. Swiss Cheese Model Modified from Reason, 1991 © 1991, James Reason Triggers DEFENSES Accident Institution Organization Profession Team Individual Technical Regulatory Narrowness Incomplete Procedures Mixed Messages Production Pressures Responsibility Shifting Inadequate Training Attention Distractions Deferred Maintenance Clumsy Technology LATENT FAILURES Goal Conflicts and Double Binds The World
    10. 10. Two Way Street <ul><li>Best understood as a dialogue </li></ul><ul><ul><li>an interaction that fosters common ground, empathy, and equity to transfer necessary information </li></ul></ul>Gibson CS, et al. Ann Emerg Med 2009 <ul><li>Sender must paint a picture </li></ul><ul><ul><li>receiver must see it, understand it, act on it, and, ultimately, communicate it to someone else </li></ul></ul>
    11. 11. Signout Skills Exercise
    12. 12. Mock Chart <ul><li>10 Minutes to Review H&P </li></ul><ul><li>Look at the blank signout template and abstract any critical data that you think will be important </li></ul>
    13. 13. Interval Events Video <ul><li>Now we will watch a short video (<3 minute video) that will highlight the events of the day </li></ul><ul><li>During the video, take note of any changes or updates that you would like to include on your signout </li></ul>
    14. 14. http://web.me.com/johnparo/MedSchoolRock/oshe.html
    15. 15. Execute a Signout <ul><li>When you are ready, turn to your partner to execute the signout </li></ul>
    16. 16. Hand-off CEX <ul><li>Receiver complete this evaluation on the sender </li></ul><ul><li>Domains assessed: </li></ul><ul><ul><li>Organization/Efficiency </li></ul></ul><ul><ul><li>Communication skills </li></ul></ul><ul><ul><li>Clinical judgment </li></ul></ul><ul><ul><li>Professionalism </li></ul></ul><ul><li>9-point scale </li></ul>
    17. 17. Volunteers <ul><li>Come up and demonstrate a handoff </li></ul>
    18. 18. How to Execute a Signout
    19. 19. Core Components of Handoffs <ul><li>Verbal Communication </li></ul><ul><ul><li>In person or over phone </li></ul></ul><ul><li>Written communication </li></ul><ul><ul><li>Signout </li></ul></ul><ul><li>Transfer of Professional Responsibility </li></ul>
    20. 20. Written Sign-out Review <ul><li>Constructing a written sign-out </li></ul><ul><li>To abstract from H&P </li></ul><ul><ul><li>Information that may become important in a critical situation </li></ul></ul><ul><ul><ul><li>Code status/iv access/PCP/family contact info etc. </li></ul></ul></ul><ul><ul><ul><li>Admission diagnosis, Admission date, team members caring for patient </li></ul></ul></ul><ul><ul><li>All patients </li></ul></ul><ul><ul><ul><li>Even those that are discharged that day </li></ul></ul></ul><ul><ul><li>Avoid vague language </li></ul></ul><ul><ul><ul><li>“ tomorrow/ today/ yesterday” </li></ul></ul></ul>
    21. 21. 9 D’s <ul><li>iDentity / Doctor / DNR or other directive? </li></ul><ul><li>Diagnosis & Diseases </li></ul><ul><li>Diet </li></ul><ul><li>Drugs </li></ul><ul><li>Daily Progress </li></ul><ul><li>Directions </li></ul><ul><ul><li>If/then </li></ul></ul><ul><ul><li>To Do </li></ul></ul>
    22. 22. iDentitiy <ul><li>Room Number </li></ul><ul><li>First thing is location (7 th vs 11 th fl) </li></ul><ul><li>Patient Name </li></ul><ul><ul><ul><ul><ul><li>Last Name </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>First Name </li></ul></ul></ul></ul></ul><ul><li>Age, Gender </li></ul><ul><li>Medical Record # </li></ul>726 Yazici,Cemal 30M 135791
    23. 23. Diagnosis and Disease <ul><li>Can place under the same column </li></ul><ul><li>Diagnosis first </li></ul><ul><li>It is the reason for admission. </li></ul><ul><li>The main problem that is being managed/worked up </li></ul><ul><li>Than the Disease (Co-Morbidities) </li></ul>CHF Exacerbation CAD, HTN, DM, ASTHMA
    24. 24. Drugs <ul><li>Sometimes difficult to list all of them </li></ul><ul><ul><li>Still possible </li></ul></ul><ul><ul><li>Can use small font </li></ul></ul><ul><ul><li>Can use abbreviations </li></ul></ul><ul><ul><li>Can highlight important ones (antibiotics, narcotics, anticoagulants, </li></ul></ul><ul><li>If you use cut/paste from EMR, have to spend time to remove unnecessary info </li></ul>
    25. 25. Diet <ul><li>Many calls about NPO status </li></ul><ul><li>Especially in patients going to surgery or procedures the next day </li></ul><ul><li>Does not take any space at all </li></ul><ul><li>Can easily be listed as </li></ul><ul><ul><ul><ul><ul><li>REG </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CLD </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>SMD </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>ADA </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>LOW K… </li></ul></ul></ul></ul></ul>
    26. 26. Daily Progress/Plan <ul><li>Things that explain patient’s CURRENT condition, progress, interventions,problems, plans. </li></ul>On Lasix 40mg IV q12 hrs , Neg Bal of 1500cc/24hrs. Improving 2D Echo with EF of 30% Continue diuresis. Cardiology to evaluate
    27. 27. Directions <ul><li>Items To Do  Only important things that needs to be addressed or requires follow up </li></ul><ul><ul><li>With special instructions with further plans & rationale </li></ul></ul><ul><li>If/then – anticipatory guidance for what may happen </li></ul><ul><li>Short and clear </li></ul>to Do Re-evaluate later tonight. Make sure receives Duoneb DIRECTIONS If gets SOB,can give IV Lasix 20mg.
    28. 28. Updating Written Sign-out <ul><li>Update daily – need to build in time to do this! </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>ideally integrated with EHR but few hospitals have this capability </li></ul></ul></ul><ul><ul><li>Directions </li></ul></ul><ul><ul><ul><li>“ to Do” with specific rationale / instruction </li></ul></ul></ul><ul><ul><ul><ul><li>Avoid “Check BMP” without giving instruction </li></ul></ul></ul></ul><ul><ul><ul><li>“ If/then” – what may happen and what to do about it </li></ul></ul></ul>Arora, et al, JGIM. 2008
    29. 29. Importance of Updating <ul><li>When comparing meds on sign-out to patient charts, nearly 1/3 discrepant </li></ul><ul><ul><li>80% contained at least 1 med omission; 40% one commission </li></ul></ul><ul><li>Omissions more common; BUT commissions more serious </li></ul><ul><ul><li>Anticoagulants, iv antibiotics, pain medications like narcotics, hypoglycemics (insulin etc.) </li></ul></ul>Arora, et al, JGIM. 2008 <ul><li>Over half had the potential to cause significant harm to patients </li></ul><ul><ul><li>Majority persisted after first day - mechanism failure to update </li></ul></ul>
    30. 30. A Word of Caution on Technology <ul><li>Computerized sign-out </li></ul><ul><ul><li>Brigham and Women’s Hospital ( Petersen, et al. Jt Comm J Qual Improv, 1998) </li></ul></ul><ul><ul><li>U Washington (Van Eaton, et al. J Am Coll Surg, 2005) </li></ul></ul><ul><li>IT solutions alone cannot substitute for a “successful communication act” </li></ul><ul><ul><li>Human vigilance still required </li></ul></ul>Ash et al. JAMIA, 2004 and Kilpatrick et al. BMJ, 2001. <ul><ul><li>In an emergency room, the replacement of a phone call for critical lab values with an electronic results-reporting system with no verbal communication resulted in 45% (1443/3228) of urgent lab results to go unchecked. </li></ul></ul>
    31. 31. Another Caution: CoPaGA Syndrome <ul><li>CoPaGA = Copy Paste Gone Amok </li></ul><ul><li>Repeated highlighting, copying and pasting text from past EHR notes into current notes, the physician-victim attains several goals; </li></ul><ul><ul><li>avoiding time-consuming work of talking to patient </li></ul></ul><ul><ul><li>building a documentation trail that portrays faux work </li></ul></ul><ul><ul><li>crowd-out of useful information by gluts of useless data </li></ul></ul><ul><ul><li>zombie-like propagation of inaccuracies that persist </li></ul></ul>74% of Mercy residents saw cut/paste problems in signout
    32. 32. TMI? Information Overload <ul><li>Overreliance on signouts for your own work </li></ul><ul><ul><li>Signouts become unnecessarily long shadow chart </li></ul></ul><ul><ul><li>Often becomes a personal tracker of information </li></ul></ul><ul><ul><ul><li>“ cognitive artifact” like a grocery list </li></ul></ul></ul><ul><li>But remember your COVERING INTERN needs it simple </li></ul><ul><ul><li>Information overload </li></ul></ul>
    33. 33. Improving Handoffs: How to Communicate Better Verbally “ who says what to whom in what channel with what effect” Harold Dwight Lasswell
    34. 34. Psychology of Miscommunication <ul><li>Speakers systematically overestimate how well their messages are understood by listeners </li></ul><ul><li>Egocentric heuristic – Senders assume that receiver has all the same knowledge that they do </li></ul><ul><ul><li>Worsens better you know someone </li></ul></ul><ul><li>Study of pediatric handoffs </li></ul><ul><ul><li>Optimal environment </li></ul></ul><ul><ul><li>Dedicated room & time </li></ul></ul><ul><ul><li>Supervised by senior resident & attending physicians </li></ul></ul>Keysar, et al. Psychol Sci. 2002; J Pers Soc Psychol. 2004; Intercultural Pragmatics. 2007
    35. 35. Same Biases in Signout <ul><li>The most important piece of information was NOT communicated 60% of the time </li></ul><ul><ul><li>despite the sender believing it had been </li></ul></ul><ul><li>Did not agree on the rationales provided for 60% of items </li></ul><ul><ul><li>At times contradictory (pt going home vs. pt needed to stay) </li></ul></ul><ul><li>Some things more likely to be remembered… </li></ul><ul><ul><li>To do items (65%) & If/then items (69%) more likely to be remembered than knowledge items (35%), p=0.003 </li></ul></ul>Chang V, et al. Pediatrics 2010
    36. 36. So What Can Senders Do? <ul><li>Think about the “R”eceiver (4Rs) </li></ul><ul><li>Relevant items that will be Remembered </li></ul><ul><ul><li>Focus on sickest patients first </li></ul></ul><ul><ul><li>Daily progress (today’s baseline, updated events) </li></ul></ul><ul><ul><li>Direction  To Do Items and If/then items </li></ul></ul><ul><li>Directions with Rationale </li></ul><ul><ul><li>avoid ambiguity  “check CBC” without giving a reason why and what to do with results </li></ul></ul><ul><li>Check for receiver understanding </li></ul><ul><ul><li>Encourage questions and read-back </li></ul></ul><ul><ul><li>Overcome egocentric heuristic (think about receiver) </li></ul></ul>
    37. 37. What Can Receivers Do? <ul><li>Actively listen </li></ul><ul><ul><li>stay focused, limit interruptions, taking notes can enhance memory </li></ul></ul><ul><li>Ask questions </li></ul><ul><ul><li>to ensure you understand directions </li></ul></ul><ul><ul><li>the handoff is your learning opportunity </li></ul></ul><ul><li>Use a system </li></ul><ul><ul><li>to keep track of to do items that require your action </li></ul></ul><ul><li>Readback </li></ul><ul><ul><li>directions to ensure you are on the same page </li></ul></ul>
    38. 38. Use of Read-Backs in Healthcare <ul><li>“ Read-back” </li></ul><ul><ul><li>Reduces errors in lab reporting </li></ul></ul>“ Read-backs” at your neighborhood Drive-Thru Barenfanger, et al. Am J Clin Pathol, 2004. 29 errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.
    39. 39. Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR? OK, this is our sickest patient, and he’s full code. I Identifying data (one liner) Mr. Jones is a 77-year-old gentleman with a right middle lobe pneumonia. G General hospital course He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin. N New events of day Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable chest x-ray was improved from admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. O Overall health status Right now he is satting 98% on 2 L NC and is afebrile. U Upcoming possibilities with plan and rationale If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because possible sepsis. T Tasks to complete overnight with plan, rationale I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up. ? Any questions? Any questions?
    40. 40. Some Case Examples… Based on real signouts…
    41. 41. A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?
    42. 42. Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?
    43. 43. A patient you are covering is being evaluated for small bowel obstruction. The attending surgeon comes by after being in the OR and asks you what the patient’s coags are. You say, I’m sorry but that is not my patient. Handoffs are more than just a transfer of content, but also a transfer of professional responsibility Every patient is your patient
    44. 46. EXTRA SLIDES
    45. 47. Case of SBAR <ul><li>Originated in Navy to communicate critical situations </li></ul><ul><li>Adapted for nurse to physician communication </li></ul><ul><li>Became most commonly described handoff mneumonic </li></ul>
    46. 48. Misuse of SBAR <ul><li>Using “SBAR” as a verb </li></ul><ul><ul><li>“ I’m SBARing” </li></ul></ul><ul><li>Failing to customize and specify the precise elements in each category </li></ul><ul><ul><li>Likely that situation for a L&D unit differs from a geriatrics unit </li></ul></ul><ul><li>Assumption that using SBAR checklist will result in comprehensive information transfer </li></ul>
    47. 49. SBAR Arora, Johnson, Jt Comm J Qual Patient Saf. Schilling, eds. 2009

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