Standardize Communication to Reduce Medical Errors

DENVER – Do you speak in SBAR?

If not, communication in your department probably could be better, two speakers said at the annual meeting of the American College of Emergency Physicians, in a session on improving teamwork.

SBAR is the acronym for a standardized communication format that organizes the transfer of information under four themes – situation, background; assessment, and recommendation. Developed by anesthesiologist Dr. Michael Leonard and colleagues at Kaiser Permanente of Colorado, Evergreen, the SBAR tool has been endorsed by many national organizations and medical accreditation bodies, said Dr. Jennifer L. Wiler.

Sherry Boschert/IMNG Medical Media

It originally was used for acute-care communications from nurses to physicians but now is being used more widely for communication from nurse to nurse and from physician to physician in a variety of care settings. One study found that it was particularly useful for reporting changes in a patient’s status or a patient’s deterioration between health care services or shifts (Healthcare Quarterly 2008;11:72-9).

Using SBAR won’t necessarily save you time – at least one study suggests it increases time for communications. The limited data from seven published studies so far suggest that SBAR use improves the transfer of important information, the perception of a culture of safety, and patient satisfaction, though SBAR has yet to be validated in an emergency department setting, said Dr. Wiler of the University of Colorado, Aurora.

It has worked in hospital medicine. Hospitalists with Kaiser Permanente found SBAR to be helpful, according to a study conducted from May 2008 to August 2009. SBAR was used for end-of-rotation patient handoffs, the researchers wrote. "The Hospitalist Chief finds SBAR useful when communicating with consultants, especially during the initial telephone conversation when it is important for hospitalists to clearly state information needs." Hospitalists communicate primarily with ED physicians, and "communications with KP ED physicians is superb; [we] get a complete diagnosis" (Perm. J. 2011 Summer;15:51-60).

The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) list communication problems as the No. 1 cause of medical error, she noted. "Addressing errors related to communication is really critical," Dr. Wiler said.

To communicate in SBAR, use the following structure:

– Situation. Identify yourself, your occupation and where you are calling from, if speaking by phone. Identify the patient – the name, date of birth, age, and sex, and the reason for your report. Describe the current status of the patient or your reason for calling. If it’s urgent, say so.

– Background. Give the patient’s presenting complaint, any relevant past medical history, and a brief summary of background.

– Assessment. Describe abnormal vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation, pain scale, or level of consciousness). Provide your clinical impression, the severity of the patient’s situation, and any additional concerns.

– Recommendation. Explain what you require, how urgently, and when action needs to be taken. Suggest what action might be taken. Clarify what action you expect to be taken.

One of the challenges to good communication is that physicians and nurses practice in parallel environments and too seldom prioritize teamwork, said Eric Christensen, R.N.

Beyond SBAR, a variety of strategies can improve communication between team members, he said. For example, the AHRQ suggests a structured handoff sign-out protocol dubbed ANTICipate (for Administrative data, New clinical information, Tasks to be performed, Illness severity, and Contingency plans).

Develop structured communication events specific to your hospital or department, suggested Mr. Christensen, a staff nurse at Denver Health Medical Center.

These might include a patient’s physiologic parameters that trigger an alert to the nurse and doctor, or required communication to reconcile abnormal vital signs. A "time out" at discharge will lead to safer discharge if all providers are aware of the treatment plan and pending issues are resolved. Face-to-face debriefings at shift changes are a good idea. He also recommended greater use of physician-nurse huddles to discuss significant patient issues, therapies, oxygen status and last vital signs, and any pending issues in clinical management.

"One of the things we’ve done at our institution is to institute huddles throughout the shift," he said in an interview. Every 2-3 hours the nurses and physicians round together to make sure throughout the shift that everyone is "on the same page."

At Dr. Wiler’s institution, team-based huddles are standard practice at presentation of more acute, sicker patient or trauma patients. "We’re moving to that methodology with all our patients," she said in an interview.

If you have concerns to raise with nurses, resist the temptation to direct them only to the most senior nursing staff, Mr. Christensen said. "It makes a world of difference to address a nurse by name," he added. If you don’t know a nurse’s name, ask directly, so the nurse feels included.

Taking 2 minutes to discuss the plan of care for complicated patients directly with the nurse and seek the nurse’s input will pay off in the long run, he said. With any patient, providing brief targeted bedside education for nurses by not just saying what will be done, but why, gets nurses more engaged in the clinical care team and better prepared to anticipate treatment of similar patients in the future.

Being approachable and complimenting nurses who are doing a good job also pays off, Mr. Christensen said.

"Be a leader, not a commander," he said. "Managers manage process and leaders lead people. If you want to know which you are, just look behind you. If there is no one there, you are just going for a walk."

Dr. Wiler and Mr. Christensen reported having no financial disclosures.

DENVER – Do you speak in SBAR?

If not, communication in your department probably could be better, two speakers said at the annual meeting of the American College of Emergency Physicians, in a session on improving teamwork.

SBAR is the acronym for a standardized communication format that organizes the transfer of information under four themes – situation, background; assessment, and recommendation. Developed by anesthesiologist Dr. Michael Leonard and colleagues at Kaiser Permanente of Colorado, Evergreen, the SBAR tool has been endorsed by many national organizations and medical accreditation bodies, said Dr. Jennifer L. Wiler.

Sherry Boschert/IMNG Medical Media

It originally was used for acute-care communications from nurses to physicians but now is being used more widely for communication from nurse to nurse and from physician to physician in a variety of care settings. One study found that it was particularly useful for reporting changes in a patient’s status or a patient’s deterioration between health care services or shifts (Healthcare Quarterly 2008;11:72-9).

Using SBAR won’t necessarily save you time – at least one study suggests it increases time for communications. The limited data from seven published studies so far suggest that SBAR use improves the transfer of important information, the perception of a culture of safety, and patient satisfaction, though SBAR has yet to be validated in an emergency department setting, said Dr. Wiler of the University of Colorado, Aurora.

It has worked in hospital medicine. Hospitalists with Kaiser Permanente found SBAR to be helpful, according to a study conducted from May 2008 to August 2009. SBAR was used for end-of-rotation patient handoffs, the researchers wrote. "The Hospitalist Chief finds SBAR useful when communicating with consultants, especially during the initial telephone conversation when it is important for hospitalists to clearly state information needs." Hospitalists communicate primarily with ED physicians, and "communications with KP ED physicians is superb; [we] get a complete diagnosis" (Perm. J. 2011 Summer;15:51-60).

The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) list communication problems as the No. 1 cause of medical error, she noted. "Addressing errors related to communication is really critical," Dr. Wiler said.

To communicate in SBAR, use the following structure:

– Situation. Identify yourself, your occupation and where you are calling from, if speaking by phone. Identify the patient – the name, date of birth, age, and sex, and the reason for your report. Describe the current status of the patient or your reason for calling. If it’s urgent, say so.

– Background. Give the patient’s presenting complaint, any relevant past medical history, and a brief summary of background.

– Assessment. Describe abnormal vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation, pain scale, or level of consciousness). Provide your clinical impression, the severity of the patient’s situation, and any additional concerns.

– Recommendation. Explain what you require, how urgently, and when action needs to be taken. Suggest what action might be taken. Clarify what action you expect to be taken.

One of the challenges to good communication is that physicians and nurses practice in parallel environments and too seldom prioritize teamwork, said Eric Christensen, R.N.

Beyond SBAR, a variety of strategies can improve communication between team members, he said. For example, the AHRQ suggests a structured handoff sign-out protocol dubbed ANTICipate (for Administrative data, New clinical information, Tasks to be performed, Illness severity, and Contingency plans).

Develop structured communication events specific to your hospital or department, suggested Mr. Christensen, a staff nurse at Denver Health Medical Center.

These might include a patient’s physiologic parameters that trigger an alert to the nurse and doctor, or required communication to reconcile abnormal vital signs. A "time out" at discharge will lead to safer discharge if all providers are aware of the treatment plan and pending issues are resolved. Face-to-face debriefings at shift changes are a good idea. He also recommended greater use of physician-nurse huddles to discuss significant patient issues, therapies, oxygen status and last vital signs, and any pending issues in clinical management.

"One of the things we’ve done at our institution is to institute huddles throughout the shift," he said in an interview. Every 2-3 hours the nurses and physicians round together to make sure throughout the shift that everyone is "on the same page."

At Dr. Wiler’s institution, team-based huddles are standard practice at presentation of more acute, sicker patient or trauma patients. "We’re moving to that methodology with all our patients," she said in an interview.

If you have concerns to raise with nurses, resist the temptation to direct them only to the most senior nursing staff, Mr. Christensen said. "It makes a world of difference to address a nurse by name," he added. If you don’t know a nurse’s name, ask directly, so the nurse feels included.

Taking 2 minutes to discuss the plan of care for complicated patients directly with the nurse and seek the nurse’s input will pay off in the long run, he said. With any patient, providing brief targeted bedside education for nurses by not just saying what will be done, but why, gets nurses more engaged in the clinical care team and better prepared to anticipate treatment of similar patients in the future.

Being approachable and complimenting nurses who are doing a good job also pays off, Mr. Christensen said.

"Be a leader, not a commander," he said. "Managers manage process and leaders lead people. If you want to know which you are, just look behind you. If there is no one there, you are just going for a walk."

Dr. Wiler and Mr. Christensen reported having no financial disclosures.

DENVER – Do you speak in SBAR?

If not, communication in your department probably could be better, two speakers said at the annual meeting of the American College of Emergency Physicians, in a session on improving teamwork.

SBAR is the acronym for a standardized communication format that organizes the transfer of information under four themes – situation, background; assessment, and recommendation. Developed by anesthesiologist Dr. Michael Leonard and colleagues at Kaiser Permanente of Colorado, Evergreen, the SBAR tool has been endorsed by many national organizations and medical accreditation bodies, said Dr. Jennifer L. Wiler.

Sherry Boschert/IMNG Medical Media

It originally was used for acute-care communications from nurses to physicians but now is being used more widely for communication from nurse to nurse and from physician to physician in a variety of care settings. One study found that it was particularly useful for reporting changes in a patient’s status or a patient’s deterioration between health care services or shifts (Healthcare Quarterly 2008;11:72-9).

Using SBAR won’t necessarily save you time – at least one study suggests it increases time for communications. The limited data from seven published studies so far suggest that SBAR use improves the transfer of important information, the perception of a culture of safety, and patient satisfaction, though SBAR has yet to be validated in an emergency department setting, said Dr. Wiler of the University of Colorado, Aurora.

It has worked in hospital medicine. Hospitalists with Kaiser Permanente found SBAR to be helpful, according to a study conducted from May 2008 to August 2009. SBAR was used for end-of-rotation patient handoffs, the researchers wrote. "The Hospitalist Chief finds SBAR useful when communicating with consultants, especially during the initial telephone conversation when it is important for hospitalists to clearly state information needs." Hospitalists communicate primarily with ED physicians, and "communications with KP ED physicians is superb; [we] get a complete diagnosis" (Perm. J. 2011 Summer;15:51-60).

The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) list communication problems as the No. 1 cause of medical error, she noted. "Addressing errors related to communication is really critical," Dr. Wiler said.

To communicate in SBAR, use the following structure:

– Situation. Identify yourself, your occupation and where you are calling from, if speaking by phone. Identify the patient – the name, date of birth, age, and sex, and the reason for your report. Describe the current status of the patient or your reason for calling. If it’s urgent, say so.

– Background. Give the patient’s presenting complaint, any relevant past medical history, and a brief summary of background.

– Assessment. Describe abnormal vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation, pain scale, or level of consciousness). Provide your clinical impression, the severity of the patient’s situation, and any additional concerns.

– Recommendation. Explain what you require, how urgently, and when action needs to be taken. Suggest what action might be taken. Clarify what action you expect to be taken.

One of the challenges to good communication is that physicians and nurses practice in parallel environments and too seldom prioritize teamwork, said Eric Christensen, R.N.

Beyond SBAR, a variety of strategies can improve communication between team members, he said. For example, the AHRQ suggests a structured handoff sign-out protocol dubbed ANTICipate (for Administrative data, New clinical information, Tasks to be performed, Illness severity, and Contingency plans).

Develop structured communication events specific to your hospital or department, suggested Mr. Christensen, a staff nurse at Denver Health Medical Center.

These might include a patient’s physiologic parameters that trigger an alert to the nurse and doctor, or required communication to reconcile abnormal vital signs. A "time out" at discharge will lead to safer discharge if all providers are aware of the treatment plan and pending issues are resolved. Face-to-face debriefings at shift changes are a good idea. He also recommended greater use of physician-nurse huddles to discuss significant patient issues, therapies, oxygen status and last vital signs, and any pending issues in clinical management.

"One of the things we’ve done at our institution is to institute huddles throughout the shift," he said in an interview. Every 2-3 hours the nurses and physicians round together to make sure throughout the shift that everyone is "on the same page."

At Dr. Wiler’s institution, team-based huddles are standard practice at presentation of more acute, sicker patient or trauma patients. "We’re moving to that methodology with all our patients," she said in an interview.

If you have concerns to raise with nurses, resist the temptation to direct them only to the most senior nursing staff, Mr. Christensen said. "It makes a world of difference to address a nurse by name," he added. If you don’t know a nurse’s name, ask directly, so the nurse feels included.

Taking 2 minutes to discuss the plan of care for complicated patients directly with the nurse and seek the nurse’s input will pay off in the long run, he said. With any patient, providing brief targeted bedside education for nurses by not just saying what will be done, but why, gets nurses more engaged in the clinical care team and better prepared to anticipate treatment of similar patients in the future.

Being approachable and complimenting nurses who are doing a good job also pays off, Mr. Christensen said.

"Be a leader, not a commander," he said. "Managers manage process and leaders lead people. If you want to know which you are, just look behind you. If there is no one there, you are just going for a walk."

Dr. Wiler and Mr. Christensen reported having no financial disclosures.