Patient Safety and Quality Improvement
Peter Michelson
Kevin O’Bryan
Upholding patient safety is critically important in providing effective care to patients. Reducing adverse medical events and associated harm is essential for all health care providers. Constant vigilance to prevent medical errors requires the cooperation of the entire health care team. To reduce errors and provide safe care to patients, health care systems must be redesigned and highly reliable processes incorporated. Only with these efforts will health care quality improve and safe and effective patient care become possible.
To develop a culture of safety, and to incorporate high-reliability practices, teaching hospitals must integrate physicians into all phases of quality improvement efforts. Medical students and residents deliver a substantial percentage of direct patient care in these institutions and directly impact patient care outcomes through their knowledge, skills, and attitudes. Furthermore, residents’ active participation in all phases of health care makes them a powerful force for changing hospital culture. Efforts focused on improved communication during handovers and transfers of care, serve as educational experiences for the entire health care team, as well as provide opportunities to reduce preventable errors. Incorporating trainee physicians into quality improvement activities not only improves their knowledge and confidence but also engages these key stakeholders in promoting the principles of safety and quality.
HANDOFFS AND SIGN-OUTS
With the advent of duty hour restrictions and the transition of medical care to more shift-based care models, patient care responsibility is frequently handed off from provider to provider throughout an inpatient visit. It is well recognized that these transitions in care are high risk and frequently implicated in medical errors that reach patients. To address this, it is recommended that all providers complete handoffs in a standardized fashion to ensure that required information is transmitted successfully. There are a number of ways to do so including using the I-PASS pneumonic for standardized sign-out. I-PASS stands for: Illness severity, Patient summary, Action list, Situational awareness with contingency planning, as well as Synthesis by receiver.
Regardless of what system is used, there are a number of components that are essential:
Minimization of distractions: Accurate sign-out between care services is critical to providing safe care. This should be allowed to happen in a quiet environment with the minimum of distractions. This may mean working with nursing staff and peers to establish a quiet “no interruptions” time and/or a separated area dedicated especially for this activity.
Handoffs should follow a standardized process: The handoff should be performed according to a standard workflow that applies to all patients. By following a standardized
approach, both the giver and receiver of information know what to expect next and can hold each other accountable to providing full, accurate information in the correct order.
Closed loop communication: The person receiving the sign-out repeats back his or her understanding of the patient to the person giving sign-out to ensure that critical information is understood. Not all the data need be repeated back, but critical elements should be restated such that the giver can assess the receiver’s understanding of the handoff and ensure its accuracy. There are other handoffs that occur on a less frequent basis throughout care delivery including transitions in care provider teams. This can be when a patient is transferred in or out of an ICU or goes to the operating room. This can also be when a patient is admitted or discharged from the hospital and transitions between outpatient and inpatient providers. During these transitions, a modified verbal handoff should occur similar to the model described above. Because these occur between different structures, such as a pediatric clinic and a hospital ward unit, regrettably, these interactions are more difficult to structure and standardize.
WRITTEN COMMUNICATION
Written communication is another important component of providing safe care to patients. To supplement the verbal handoffs during these transitions in care, written confirmation is required. This can be a transfer note, an off service note, or a discharge summary depending on the situation. Timeliness is essential for this written supplement to be effective. Documents of this nature should be completed as soon as possible and ideally before the receiving caregiver provides care. This can be difficult to accomplish when a patient is transferred to the ICU but should definitely be accomplished when patients are discharged or transferred back to outpatient providers. A discharge letter should be available to any care provider in time for their follow-up visit. A good rule of thumb is that a discharge letter should be completed at least 3 days before the first outpatient appointment.
Written communication should also be accurate, legible, and easily interpretable. Most hospital systems are moving toward electronic notes that address the legibility associated with handwritten notes; however, one must still be responsible to ensure that notes are interpretable. Ideally, these notes would be concise and accurate, and provide the reader with all the necessary information to continue care. Many electronic notes are prone to “note bloat” from unnecessary use of copy and paste behaviors where extraneous or inaccurate information is copied from previous notes. These practices should be avoided, and, when used, should be done in a fashion where copied information is carefully reviewed and edited to ensure accuracy. We recommend that copy and paste only be used as a tool to ensure information is not lost between encounters and not a tool for documentation efficiency.
Another component of ensuring safe practices as well as making notes readable is the appropriate use of abbreviations. Users of abbreviations are susceptible to error because their meaning may differ between institutions and individuals. Your organization should have a list of approved and prohibited abbreviations, and if you intend to use abbreviations, you should be familiar with these rules. Listed in Table 27-1
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