Running Head: Communication Breakdown in Patient Transfers

1

Communication Breakdown

Running Head: Communication Breakdown in Patient Transfers

Communication Breakdown in Patient Transfers

In APA Style

Eric Jones

The PennsylvaniaStateUniversity

English 202c, Section 1

Julie Kearny

April 12, 2007

Abstract

Communication problems in patient transfers are the number one cause of error in the medical field today (Hospitals to, 2006). Patient transfers take place between medical facilities; during patient sign-ins and check outs, and when patients are moved from one department of the facility to a different department. The studies and examples researched prove that breakdown in communication does lead to medical errors, patient dissatisfaction, and in worst cases, patient harm. The Joint Commission regulates the standards that medical facilities need to abide by on the terms of staff communication, and the medical field is developing improvements to meet these standards

(Hospitals to, 2006).
Table of Contents

Abstract………………………………………………………………………………… 2

Introduction…………………………………………………………………………….. 4

Studies…………………………………………………………………………….. 4, 5, 6

Example……………………………………………………………………………… 6, 7

SBAR……………………………………………………………………………….7, 8, 9

Conclusion……………………………………………………………………………… 9

Reference Page…………………………………………………………………………10

Table of Figures

SBAR Package…………………………………………………………………………7
Communication Breakdown in Patient Transfers

Introduction

Communication plays an important rule in all aspects of the medical field. This ranges from written communication in patient records, medical notes, and electronic mail, to oral communication between the medical staff as well as oral communication between the staff and the patient. Without clear channels of communication between the medical staff, errors will arise and patient’s safety will be at risk. Miscommunication is the number one reason for major medical errors reported to the Joint Commission on Accreditation of Healthcare Organizations (Weaver, 2006). The Joint Commission has recently adjusted their regulations on breakdowns in communication in the medical field, which one main focus point, patient transfers (Hospitals to, 2006).

Patient transfer is the number one cause of communication error in the medical field (Hospitals to, 2006). This includes transferring a patient from one room to the next, from a family doctor to a hospital physician, nurse to doctor, and every other event in which the patient’s primary care provider is shifted. One article described patient transfers as the Bermuda Triangle of health care (Landro, 2006). It is truly in dire need of new communication standards, and there are studies done to prove it.

Studies

The Yale Bulletin and Calendar published an article on their website detailing a study that recalled the protocols medical facilities use when performing a patient transfer (Weaver, 2006). The article described that in high risk fields, communication is standardized in ways that every worker in that field understands, and uses (Weaver, 2006). Specifically detailing that when planes take off or leave they have to complete a standardized checklist to make sure everything is working as planed, which relates to when a patient is checked in or out of a medical facility (Weaver, 2006). The personal performing the study described that they were surprised that during patient transfers in medical facilities, a standardized way of communication between the current patient care provider, and the future patient care provider was not executed (Weaver, 2006).

The personal discovered this while performing a study on two hundred and two accredited internal medicine residency programs (Weaver, 2006). Through the study, the personal found that,

Over half of the hospitals that participated in the study do not inform their nurses when doctors have changed responsibility for the night. Fewer than half of programs require that information about their patients always be conveyed both in oral and written form, and fewer than half of programs provide any formal training in sign-out skills. (Weaver, 2006)

This information cements the fact that the medical field needs to standardize, and modernize its methods for communication during patient transfers. The report written for the study explained that if they had formal systems of patient transfer, it would benefit the health of the patients and containment of their medical records (Weaver, 2006). Leora Horwitz, the lead author of the study, concluded that, “These are all easily remediable processes that we know are contributing to medical errors, but only by describing and quantifying the problem can we generate sufficient interest and pressure to change the system” (Horwitz as cited in Weaver, 2006).

A different study, done by Steven H. Woolf, a professor at VirginiaCommonwealthUniversity in Fairfax, further described the adverse effects of breakdowns in communication, including patient transfers (Robeznieks, 2004). His study involved reading seventy five error reports and breaking down which error caused each report (Robeznieks, 2004). Through the study, Dr. Woolf discovered that eighty percent of errors were directly related to miscommunication, including “breakdowns between physician colleagues, misinformation in medical records, mishandling of patient requests and messages, inaccessible records and inadequate reminder systems” (Robeznieks, 2004). All of these breakdowns are involved during the transfer of a patient from one medical facility to the next.

Example

During a transfer of a one day old infant from a community hospital to an acute care facility, a communication breakdown took place which directly caused the infant to have severe injuries (International, 2003). The cause of the infant’s relocation to the acute care facility was due to a gastrointestinal bleed, which needed to be further evaluated and monitored (International, 2003). The communication breakdown occurred when a nurse noticed a darkened area around the infants IV site that occurred at the community hospital (International, 2003). She noted this on a transfer sheet and sent the infant to the intensive care unit in the acute care facility, but did not put this transfer sheet in the patient’s records (International, 2003). These errors lead to the doctors at the intensive care unit to be unsure about the condition of the infant.

The parents of the infant came in the next day and saw that the infant had a substantial injury and wanted to know what the cause was from the doctors (International, 2003). None of the doctors gave the same response as to what had caused the injury, one doctor explained that a blister had popped and left a mark, another that the original community hospital had improperly administered the IV to the infant, and a third doctor explained that the contents of the IV had a side effect of creating minor injuries to the patient (International, 2003). The injury turned out to be a third degree burn which will scar the infant forever, which upset the parents greatly (International, 2003).

The lack of a standardized transfer system to make sure that every nurse, doctor, and patients loved ones are on the same page greatly exacerbated the patient’s injury. The medical field is enhancing their systems of communication during patient transfer, and the Joint Commission is setting their standards higher for the medical facilities that lack these systems of better communication (Weaver, 2006). (SBAR product,

SBAR

The SBAR program was created by Kaiser Permanente in Colorado (Iyer, 2006). SBAR stands for Situation, Background, Assessment, Recommendation (Iyer, 2006). These are further described by Iyer in her journal as;

Situation- The personal must describe the patient’s situation including location, and the current health state (Iyer, 2006). .

Background- The personal relays important background information about the patient. This includes what the physician’s diagnosis of the patient is, and the history of the patient’s health (Iyer, 2006).

Assessment- This is the personal’s opportunity to asses the problem themselves and describe any details that they believe is very important or relevant (Iyer, 2006).

Recommendation- The personal describes what they think should be done to improve the situation (Iyer, 2006).

This technique is used to relay critical information between physicians, in sixty seconds or less (Hospitals to, 2006). Physicians have very hectic schedules is and SBAR used to provide them with correct information in a standardized fashion that the whole medical field conforms to (Iyer, 2006).

Iyer describes in her medical journal that new or fatigued personal often leave out critical information when describing the condition of a patient, or relaying critical information to other personal (Iyer, 2006). SBAR improves this type of situation by standardizing what information is relayed, and securing that all personal are informed of the important patient details.

SBAR is becoming a standard communication technique in many medical facilities, including the University Health System Consortium (Hospitals to, 2006). This University consists of ninety-five academic medical centers and in each of these the SBAR technique is being taught to the future personal of the medical field (Hospitals to, 2006). Therefore showing that the medical field is accepting SBAR as a standard communication technique because not only are they teaching it to the personal in the medical field, but students of the field are being educated with this technique as well.

Conclusion

The medical field is in great need improvement in its methods of communications. Specifically in patient transfers, the time in which the care of someone’s life is alternated from one doctor to the other. The studies and example portray this need of improvement, and the SBAR program shows that the medical field is aware of the problem, and progressing in the right direction. If every facility across the country adapts to this new program, and the has the will to improve their communication techniques, medical facilities will be a much safer place.

References

Hospitals to target patient handover communication errors. (2006, July 3). The Datamonitor Newswire “electronic version”. Retrieved April 17, 2007, from the LexisNexis database.

International Journal for Quality in Health Care, 15. (2003).Retrieved April 15, 2007, from Oxford Journals: /cgi/content/full/15/5/441

Iyer, Patricia (2006). Aritcles: Medical Errors: SBAR. Retrieved April 30, 2007, from

Landro, Laura. (2006, June). Hospitals combat errors at the “hand-off”. Assosiciated Press Financial Wire. Retrieved April 20, 2007, from LexisNexis database.

Robeznieks, A. (2004). Communication problems often initiate “cascades” of errors. Retrieved April, 17, 2006, from amednews.com: amednews/2004/08/06/prsa0816.htm

Weaver, J. (2006). Study calls for reforms in the patient transfer protocols. Yale Bulletin & Calendar, 34. Retrieved April 17, 2007, from n31/story.html