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Slide Notes

Communication is the most important piece to patient safety when transferring a patient from one unit to another. Patton, Tidewell, Falder-Saeed, Young, Lewis, & Binder (2017) bring to our attention that the handoff should be thought of as high risk
due to break-down of communication, which can lead to error or omissions leading to patient harm if more care and responsibility is not taken. Working in Labor and delivery as a nurse, we want to make sure to pass on to the next nurse in post-partum, everything that we know about the patient's health as well as what took place in delivering her baby. This also includes the information we have learned about the baby.
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Communication Workflow-promoting patient safety upon transfer from unit to unit. *view notes with each slide* By: Christie DeWeese BS, RN, IBCLC

Published on Feb 10, 2020

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1.

Communication Workflow-promoting patient safety upon transfer from unit to unit.

*view notes with each slide*


By: Christie DeWeese BS, RN, IBCLC

Communication is the most important piece to patient safety when transferring a patient from one unit to another. Patton, Tidewell, Falder-Saeed, Young, Lewis, & Binder (2017) bring to our attention that the handoff should be thought of as high risk
due to break-down of communication, which can lead to error or omissions leading to patient harm if more care and responsibility is not taken. Working in Labor and delivery as a nurse, we want to make sure to pass on to the next nurse in post-partum, everything that we know about the patient's health as well as what took place in delivering her baby. This also includes the information we have learned about the baby.
Photo by Paul Cowell
2.

Hand off Report Sheet/SBAR: with the most up to date patient information

Each nurse can utilize the same type of report sheet so that all of the patient information is available at all times, even in the event of an emergency. This type of communication is also known as SBAR. SBAR stands for Situation, background, assessment and recommendation for the patient which can be very effective as discussed by Yu and Kang (2017).This same form can then be used when transferring the patient after delivery over to the post-partum unit. As shown on this report sheet, we are able to list allergies, blood type, Hep B and HIV status, medications taken, delivery and baby information, etc.
3.

BEdside Report

include the patient in their care
When the Labor and Delivery nurse brings the patient to the post-partum unit, they should stay in the room with the patient. After asking the patient for permission to discuss her health and delivery information, they should use the report sheet to tell the story of the patient from start of her admission adding everything known. Then it is important to double check with the patient if she believes anything needs to be added.
Photo by Sharon McCutcheon
4.

Nurse dual sign off:

IV medication and Electronic Health Record
After giving report, it is important to open the Electronic Health Record (EHR) with the nurse who is taking over care of the patient. There are IV medications that are running such as pitocin. This is a high risk medication and needs to be checked within the record as well as the pump to ensure it is running safely. Many EHR's will communicate with the pump so we want to make sure as the nurse we have the right patient, the correct medication running at the appropriate rate in order to reduce errors according to Mourad (2018).
5.

Summary

  • Communication is key to ensure patient safety.
  • Use Report Sheet/SBAR form to ensure you are giving all patient information.
  • Transfer and Give Bedside Report with patient acknowledgement.
  • Make sure to open EHR and sign off IV medication.
Photo by Christopher Boswell
6.

References

please see notes 
Mourad, H. (2018). EHR associated medication errors – Are we reducing errors? Retrieved from https://connect.ashp.org/blogs/hesham-mourad/2018/05/17/ehr-associated-medi...
Patton, L.J., Tidewell, J.D., Falder-Saeed, K.L., Young, V.B., Lewis, B.D., and Binder, J.F. (2017). Ensuring safe transfer of pediatric patients: A quality improvement project to standardize handoff communication. Journal of Pediatric Nursing, 34, pp. 44-52. doi.org/10.1016/j.pedn.2017.01.004
Yu, M., and Kang, K.J. (2017). Effectiveness of a role-play simulation program involving the SBAR technique: A quasi-experimental study. Nursing Education Today, 53, pp. 41-47. doi: 10.1016/j.nedt.2017.04.002

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