The Science Journal of the American Association for Respiratory Care

2011 OPEN FORUM Abstracts


Khris E. O'Brien, Julia Halvorson, Luanne Jerving, Sharon Graves, Rhonda Duerst; Respiratory Care Services, Children's Hospital of Wisconsin, Milwaukee, WI

Background: The Joint Commission (TJC) has identified handoff periods as high risk events for patient safety. At Children's Hospital of Wisconsin (CHW), communication is a contributing factor in a majority of high level adverse events. To improve communication effectiveness, TJC identified key elements to be incorporated into care provider handoffs. One element includes minimizing or eliminating distractions/interruptions during handoffs. In early data, respiratory therapists (RT) had difficulty recognizing distractions/interruptions. Once identified, systems barriers were overcome to reduce them when possible. Methods: Utilizing a Plan-Do-Study-Act (PDSA) rapid cycle improvement approach, we conducted random handoff "face to face" interviews monthly to test the elements of provider handoffs. One of these elements included an evaluation of distractions/interruptions. During the interview process, we discovered that staff didn't recognize distractions/interruptions as occurring. Over time, the survey question was clarified to the following question to prompt potential distractions/interruptions: Were there any distractions or interruptions during report? e.g.: pager, Vocera, printer, people talking/interrupting. If yes, list the number of times interrupted/distracted and specify what they were.I Using this method, the following key interruptions and distractions were identified: o Staff (RT & other services) not involved in the handoff interrupted the report. o A printer in critical care areas printed nursing report sheets during Respiratory handoff. Two key strategies were deployed to reduce distractions and interruptions. 1.Report room doors were closed and signage stating "Handoff in Progress-No Interruptions" were placed outside of the room during handoff. 2.Nursing printers were relocated to non-handoff locations. Results: The following graph illustrates the process of helping staff identify distractions/interruptions and the steps taken to reduce/minimize them. Conclusions: Recognizing and reducing distractions/interruptions is only one process improvement opportunity we have undertaken to incorporate TJC required elements into our Respiratory Care handoffs at CHW. Utilizing the PDSA cycle, intent, content, process and team effectiveness have been identified as key drivers to improve handoff. Work is ongoing in all of these areas to improve the communication effectiveness of our staff and to reduce the potential of handoff related events. Sponsored Research - None