Communication and Safety; It’s all a Matter of Knowing When to “stop” and When to “go”

ASPAN NATIONAL CONFERENCE ABSTRACTS

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 Improve communication between Waiting Room, Preop and OR Charge RN Process of Implementation:  Identify a process for updating patients when delays occur  Identify a standardized process for service recovery  Provide distractions (magazines, books) to alleviate stress of long wait periods Statement of Successful Practice:  Patient complaints have decreased regarding the lack of communication  Waiting Room and Preop Staff satisfaction have increased by keeping patients well informed

moted collaboration among all team members and there is now a better understanding of how important this final checklist is to provide patient safety. Implications: This process is an easy, inexpensive way to communicate with one another and it promotes and sustains TJC National Safety Goals.

“PINK BOARDING PASS”: PERIANESTHESIA/ PERIOPERATIVE TRANSFER OF CARE Team Leader: Angela Coroso, RN, BSN UPMC Passavant Hospital, Pittsburgh, Pennsylvania Team Members: Wende Goncz, DO, MMM, Elaine Wolford, MSN, RN, Kathy Gordon, MSN, RN, CNOR, Kimberley Confer, MSN, RN, CAPA, Sandy Appleton, RN, OR

Implications for Advancing Practice:  Having a standardized policy for effective communication reduces patient complaints when there are unanticipated delays  Eliminates the assumption of others updating patients  Although some patients are upset due to delays, they are more understanding when well informed

COMMUNICATION AND SAFETY; IT’S ALL A MATTER OF KNOWING WHEN TO “STOP” AND WHEN TO “GO” Team Leader: Kelly Cannizzaro, RN, CAPA The URMC Surgery Center at Sawgrass, Rochester, New York Team Members: Jean Gumina, BSN, CAPA, CPAN, Carol Ives, RNBS, CAPA, Kristen Kelly, BSN, CAPA, Stefan Lucas, MD, Cathy Wuest, RN, CAPA, Margaret Zotter, BSN

Background: In our ambulatory surgery center, there were three incidences where a patient arrived in the operating room without proper consent. We realized that we needed a safe, “at-a-glance” way to communicate when a patient had all the key elements in place prior going to the operating room. We developed “STOP” and “GO” signs to help with this process. Objectives:  Construct and implement a process that would provide better communication across all disciplines and promote safety by: B Eliminating incomplete consents. B Assuring that site marking is done. B Double checking for antibiotics, UPT results and history and physicals.  Institute a process that was easily understood and easy to enforce. Implementation: A check list and a “stop sign” were printed on a 9”x5.5” sheet of red card stock and then laminated. A “GO” was printed on the same size green card stock and laminated. The signs were put in every room along with dry erase markers. We educated all staff (nurses, surgeons and anesthesiologists). We set up clear guidelines, roles and established specific expectations. Results: This process has been extremely successful; consents, Day of Surgery Updates and site marking are consistently done prior to going to the operating room. This program has pro-

Transfer of care is the communication between healthcare providers for every patient as they move from one provider to another. The Joint Commission estimates approximately 80 percent of serious medical errors involve miscommunication during the hand-off between healthcare providers. This alarming percentage validates the need for standardization of the handoff, which is essential to providing safe patient care. The objective of the project is to enhance the quality and safety of our patients by improving communication between staff members.  There is a “Boarding Pass” generated from the surgical schedule and a work sheet is used to communicate information about the patient.  The “Boarding Pass” verifies all information on the consent matches the surgical schedule.  Upon transfer to OR, we review the work sheet and also compare “Boarding Pass” which states the patient’s name and surgery to verify accuracy.  When the patient leaves the OR the same worksheet is used by CRNA to give report to PACU nurse.  There are two sheets in use- one that the preoperative nurse transfers to CRNA and another that CRNA provides to PACU nurse. The team decided to combine these into one worksheet to ensure that the preoperative sheet stays with the patient throughout their surgical stay. In conclusion, with our standardized transfer of care we continue to focus on improving perianesthesia and perioperative communication. A survey demonstrated staff’s positive feedback toward the combination of the two work sheets. It has improved collaboration within Surgical Services resulting in a clear, organized transfer of care.

PARTNER IN CARE: IMPROVING THE PATIENT EXPERIENCE THROUGH AIDETÒ Team Leaders: Debbie Sandlin, BSN, RN, CPAN, Laura Tranter, M. ED.HRD, Nancy Atkinson, ADN, RN, CAPA, Cynthia Grothaus, BSN, RN, CNOR, Karen Tracy, RN, Teresa Burtschy, BSN, RN St. Elizabeth Healthcare, Edgewood, Kentucky Team Members: Vickie Lawson, CNA, Kathy Stephens, Nancy Welch, RN, Elizabeth Dietz, RN, Judith Schletker, RN, Janice Sanborn, RN, Patsy Goins, RN, Kimberly Edwards, RN, Susan Garrett, BSN, RN, CNOR, Lois Klaine, RN, Dawn Thomas, RN, Cindy Klein, RN, Megan Crone, BSN, RN, Carrie Herthel, RN,