Case Studies

Implementing I-SBAR

The Problem

Communication is listed as the leading factor in the root causes of sentinel events as reported to the Joint Commission for the years 1995 through 2005. As a result, in 2008, the Joint Commission added National Patient Safety Goal 2E—"Implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions."
Many medical errors can be prevented through proper communication particularly among the various nurses who encounter a patient during their hospital stay. We concluded through observation and an informal nurse's survey that none of the staff nurses had a standard that they followed for giving a report to the next caregiver.
Patient safety is a major focus here at Saint Vincent and the information we collected proved that it was necessary to develop a standard "hand-off" tool to decrease the chances of a communication error and therefore decrease the chances a of an error occurring. We were challenged in the operating room to not only develop the best patient safety guidelines,but to also develop the proper documentation standard for regulatory compliance.

The Solution

The development of a standard communication process started with information gathering from staff members at all levels of care within the surgical suite. We chose to utilize TeamSTEPPS. It is an evidence-based system to improve communication and teamwork. Additionally, the I-SBAR mnemonic was used as the base for the new hand-off tool.
The development of the printed patient record was changed to assist in proper communication of patient data. That form was completed through collaboration of the nursing staff and the technological staff to make the data flow in a standard format used every time the hand off report is given. After many revisions, a final format was developed and an educational PowerPoint presentation was given during a unit-based in-service prior to the initial change. The format and the principles have been incorporated into the orientation of all new registered nurses. The surgical patient benefits from this now standardized, conscience, complete, and accurate report that is given from the print out from all three areas of the surgical suite.

Additional Resources

Webinars December 13th, 2017

Equity of Care Webinar SeriesPart 2: Aligning Diversity and Inclusion, Community Engagement, Busi......

VIEW THIS RESOURCE
Webinars November 20th, 2017

Equity of Care Webinar SeriesPart 1: Aligning Diversity and Inclusion, Community Engagement, Busi......

VIEW THIS RESOURCE
Webinars November 17th, 2017

Transportation and the Role of Hospitals This AHA webinar on “Transportation and the Role of Hos......

VIEW THIS RESOURCE