Narrow Results Clear All
- Communication Improvement
- Human Factors Engineering 2
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 2
Search results for ""
Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Journal Article > Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Joffe E, Turley JP, Hwang KO, Johnson TR, Johnson CW, Bernstam EV. Jt Comm J Qual Patient Saf. 2013;39:495-501.
The SBAR (situation, background, assessment, recommendation) communication tool has been implemented in an effort to improve nurse–physician communication, particularly by telephone. For this simulation study, 20 nurse–physician pairs were enrolled and the nurse in each pair was randomized to receive six written clinical scenarios to convey to the physician (three using the SBAR format, three in the usual format). Investigators found that relevant information was often not communicated by the nurse nor elicited by physicians, and use of SBAR did not improve communication.
Journal Article > Commentary
Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.
Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.