Ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm. As per the Joint Commission, communication failures were implicated at the root of over 70 percent of sentinel events.
In acute care settings, communication failures lead to increase in patient harm, increased length of stay, and resource use.
Analysis of events resulting from ineffective communications revealed that communication problems could be categorised into four categories:
(1) communications that were too late to be effective.
(2) failure to communicate with all the relevant individuals of a team.
(3) content that was not consistently complete and accurate.
(4) communications whose purposes were not achieved—i.e., issues were left unresolved until the point of urgency.
Examining the outcomes of communication, researchers also found associations between better nurse-physician communication and collaboration and more positive patient outcomes, i.e., lower mortality, higher satisfaction, and lower readmission rates.
Effective communication among health care professionals is challenging due to a number of interrelated dynamics:
- Health care is complex, with professionals from a variety of disciplines involved in providing care at various times throughout the day, often distributed over several locations, creating spatial gaps with limited opportunities for regular synchronous interaction.
- Care providers often have their own disciplinary view of what the patient needs, with each provider prioritizing the activities in which he or she acts independently.
- Health care facilities have historically had a hierarchical organizational structure, with significant power differences between physicians and other health care professionals leading to a culture of inhibition and restraint in communication, rather than a system of open, safe communication.
- Differences in communication styles and methods that further complicate the scenario and render communications ineffective.
IPSG (International Patient Safety Goal) 2 speaks of “Improve Effective Communication”.
It is a well established fact that effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and improves patient safety. Patient care circumstances that can be critically impacted by poor communication include verbal and telephone patient care orders, verbal and telephone communication of critical test results, and handover communications.
Patient care orders given verbally in-person and over the telephone, are some of the most error-prone communications. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order being given. Background noise, interruptions, and unfamiliar drug names and terminology often compound the problem.
The hospital has a policy of limiting verbal communication of prescription or medication orders to urgent situations in which immediate written or electronic communication is not feasible.
Only a physician/ surgeon can give a telephone order/verbal order. A Resident / Medical Officer / Registrar can take the verbal order from treating physician (Consultant) and documents it with date and time. Doctors are trained to always follow “Read Aloud and Verified (RAV).
The hospital allows all medical staff orders for diagnosis and treatment in writing only. The medical staff member must authenticate the verbal order / telephone order within 24 hours for telephone orders with signature and date when the authentication is completed (not the date and time the order was given).
Doctor to Nurse Verbal Orders are not allowed, except in emergency situation.
Verbal orders can also be restricted to situations in which it is difficult or impossible for hard-copy or electronic order transmission, such as during a sterile procedure. Documentation can always be done and accepted in retrospect in such circumstances.
The hospital has defined the critical tests and critical test results as follows:
Critical or Urgent Test: Critical or Urgent test can be termed as stat exams, which will always require immediate communication of the results, even if normal. (List of tests which are considered Critical irrespective of urgency are listed in annexure.)
Critical Result: It indicates those findings (even if from routine tests) which are abnormal and require immediate communication of the results.
The hospital has a definite policy for Critical Test and Critical Result Reporting and staffs are trained on the same.
Laboratory, Radiology, Nuclear Medicine, Department of Non Invasive Cardiology Services, Neurology, PET CT, Obstetrics and Fetal Medicine have identified Critical Results, which are notified to the Consultant / Residents / Ward Nurses, over telephone, when such result or values are obtained.
“Read Aloud and Verified” is followed when a result of a critical test and/or critical result is reported from any of the above mentioned areas. These departments maintain results of critical test and critical result in a register to document all verbal reports conveyed over telephone.
The turnaround time for all Critical Test and Results reporting is 20 minutes from the time of availability of such results in the diagnostic areas which is monitored and improved as required.
The critical results of test in bedside through Point of Care Tests like Capillary Blood Sugar testing (Glucometer), Arterial Blood Gas Analysis; Bedside x-rays and ultrasound; and Echocardiography are notified to the Consultant (treating) physician verbally following similar procedure by the staff interpreting the test result. The staffs are trained to document the result in the critical test reporting form in the medical records.
Prior to completion of the verbal order / telephone order / critical results, the person receiving the order follows the following
- Identify the patient
- Listen the results / order correctly
- Write the results / order
- Read the results back
- Verify the result
Notation on the order includes the abbreviation “RAV” to indicate that the order was read aloud and verified, and the person taking and implementing the order records his/her name, designation, date and time along with the name of the person issuing the order.
Handovers of patient care within a hospital occur between health care providers, such as
- a) between physicians and other physicians or health care providers, from one provider to another provider during shift changes; b) between different levels of care in the same hospital such as when the patient is moved from an intensive care unit to a medical unit or from an emergency department to the operating theatre; c) from inpatient units to diagnostic or other treatment departments, such as radiology or physical therapy; d) between staff and patients/families, such as at discharge.
Breakdown in communication can occur during any handover of patient care and can result in adverse events. Interruptions and other distractions from unit activities can inhibit clear communication of important patient information. Standardized forms, tools, or methods support a consistent and complete handover process. The content of the handover communication and the form, tool, or method used is standardized for the type of handover. This is a new elaboration as per the 6th Edition, JCI standards.
SBAR format is an effective communication technique for all members of the healthcare team across the hospital. SBAR is used to communicate patient-specific information when transferring care of a patient between or among providers. SBAR stands for the following:
S – Situation: Identify yourself, your position, the patient’s name, and current situation. Describe what is going on with the patient.
B – Background: State the relevant history, physical assessment pertinent to the problem, the treatment/clinical course summary, diagnosis and any pertinent changes.
A – Assessment: Offer your conclusions about the present situation including Neurological status of the patient and any critical lab/radiology investigations. Any other concerns may also be included here.
R – Recommendations: Plan of Care and any concerns. Explain what you think needs to be done, what the patient needs, and when.
End with Questions: Verify any critical information received, review the history, seek clarification, and ask questions, and read or repeat back critical test results.
The SBAR format and technique is used when transferring care of and information about a patient during, but not limited to, the following exchanges of information:
- Between health care providers, such as between nurses, physicians and other physicians or health care providers
- From one provider to another provider during shift changes or when we take any break in between.
- Between different levels of care in the hospital such as when the patient is moved from an intensive care unit to a medical unit or from an emergency department to the operating theatre or to a procedural area like Endoscopy / Radiotherapy / Cath lab etc.
- From inpatient units to diagnostic or other treatment departments, such as Radiology, Non Invasive Cardiology or Physiotherapy .
SBAR may be used between and among all health care providers, and may be tailored for use in any exchange of information. This communication is documented in separate hand off formats by Consultants, Junior doctors, Nursing and other staff.
Data from handover communications is tracked and used to improve approaches to safe handover communication.
When possible and appropriate, the patient and family shall be informed about the transfer. The healthcare worker transferring the patient shall make the patient/family aware of the hand-off and provides the details of person or team taking responsibility for the continued care.
Tools & Documentation related to the Handover :
Formal documentation of the Handover is followed in following formats of the patient’s medical record –
- From Emergency to Critical Care Units / Ward – Details in the A&E Disposition Record
- From Critical Care Units to Wards or Wards to Critical Care – Transfer Information Sheet
- From Wards / Critical Care to Operation Theatre and Procedural Area – Pre Operative or Pre procedural Note (and Patient Tracker)
- Operation Theatre to Wards and Critical Care – Postoperative Care Plan (and Patient Tracker)
- Shift Handovers in Nurses – Nurse Care Plan
- Shift Handovers in Physicians – Patient and General Physician Handover list
- Patient Movement and Transfer from Ward to Radiology or other areas and back transfer – Patient Tracker Form
The hospital tracks adverse event data and uses the information to identify improvements for handover communications.
The hospital ensures training of all staffs on hospital policies related to ensuring effective communication. Monitoring and surveillance is conducted on a regular basis followed by discussions in Meetings to ensure compliance to the same. To improve effective communication and ensure staff awareness and compliance to the same, the month of July is dedicated for the same when road shows, awareness programs and staff engagement activities on improving effective communication is organised across the hospital.
Implementation of an escalation process tool to facilitate timely communication in the form of Early warning signs in the clinical domain and Dial 30 initiative in the service domain and daily multidisciplinary patient-cantered rounds using a daily goals sheet and morning team huddle as a part of “Ward As a Unit” initiative are other methods that will help improve effective communications between different care providers in a particular unit and reduce patient harm.
Last but not the least the hospital leadership encourages a “Culture of Safety” through stringent enforcement of policy and staff awareness. The hospital conducts a “Culture of Safety” survey once a year and takes necessary actions to encourage a robust “Culture of Safety” with free and open communication flow across all levels of healthcare providers enforcing patient safety.