2006 OPEN FORUM Abstracts
SBAR, CONSISTANT EFFECTIVE COMMUNICATION IN TRANSFER OF PATIENT INFORMATION
Carol Mihailuk
RRT, Richard Ford RRT, John
Newhart RRT, Elsie Collado-Koman RRT, Koreen Menzies RRT, Julie Emerick RRT,
Ted Vallejos RRT and Timothy Morris M.D., University of California San Diego,
Medical Center
Objective: Faulty
communication is cited as one of the root causes in over 60% of the sentinel
events reported to the Joint Commission. Breakdowns in communication during
shift report and patient handoffs can cause a wide range of medical errors.
Both JCAHO and the Institute for Healthcare Improvement (IHI) have directed
practitioners to focus on methods to improve communication, including the use
of SBAR. We assessed staff perception of report quality by developing a survey
and developed a plan for the implementation of SBAR for shift report and during
rapid response.
Method: A questionnaire was developed and given to all
respiratory therapists consisting of six questions; to assess the quality,
content and length of the report received and a self assessment to rate the
report they provide to others. To further evaluate report quality, reports on
30 patients were videotaped and critiqued for overall quality and quantity of
pertinent information. The SBAR implementation team met to design guidelines,
scripting, and an education program to train all staff in the use of SBAR.
Results: 51% of staff responded to the survey. The survey results conveyed that
therapists felt that the report they provided was excellent, while the quality
of report received was fair to poor. Both the content and duration of report
could be improved. The survey, as well as review of the videotaped reports,
indicated a structured reporting system such as SBAR would be of benefit. A
training program specific to respiratory services was developed using the IHI
resources and internal experts.
Conclusions: The report survey and the
videotaping critiques demonstrated an opportunity for improvement. The training
program based on available resources has been effective in implementing SBAR.
We will continue to assess staff perception of the quality of report as SBAR
continues to be refined for respiratory care and staff learns to better
incorporate this tool.