e1 rapid fire: passing the baton for quality care - c. masuda, k. cooksley, r. janke and t....
TRANSCRIPT
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BC Children’s Hospital &
Sunny Hill Health Center for Children
SHARED Transfer of Care:
Safe Intra-Hospital Transfer of
Patient Care
Rita Janke, Cathy Masuda, & Tracie Northway
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Clinical Transfer of Care
The transfer of professional responsibility &
accountability for some or all aspects of care for
a patient to another person or professional group
on a temporary or permanent basis (NHS)
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Why Focus on Transfer of Care?
•65% of reported sentinel events due to
communication
•Handover process unreliable & highly variable
•Failures in clinical handover major preventable cause of patient harm
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Measured Outcomes:
Preparation
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Findings
•No consistency among both RNs
•Inaccurate / incomplete information given
•Confusing info takes away from patient
•Creation / perpetuation of errors
“I don’t really
know this
patient”
“6 pages of
orders from 3
different
Physicians!”
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Determining Best Practice
Based upon literature review:–Standardization of handover content & process
–Best practices:
1. Two-way Communication
2. Face-to-Face Handovers with Written Support
3. Content of Handover Captures Expectation & Plan of Care
–Mnemonic to guide handover
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SHARED Transfer of Care
•Standardized process throughout BCCH / SHHC
•Replaces current transfer sheets, admission or transfer note, flow sheet assessment
•Supports effective communication
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SHARED Transfer of Care
SH Form
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Transfer Orders Set
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Steps in SHARED
Transfer of Care Process
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Pre-Kaizen &
Kaizen Week Defects
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Lessons Learned from RPIW
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Follow-On
•Program-specific champions
•Mediasite education on BCCH website
•Initial site-wide education for nurses Fall 2009
•SHARED process added to orientation
•Revisions to include PACU & Mental Health Process
•Inclusion of PEWS score
•Ongoing measurement via observation
•Indicator placed on PSLS to identify if event occurred during transfer of care
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Sustainment
SHARED Transfer of Care: Number of defects per transfer
Defects over time
0
5
10
15
20
25
30
Prep-week
(Jun 2009)
(n=11) 8-21
defects
RPIW Final
(n=14) 0-12
defects
Week 1 (n=2)
2-4 defects
Week 2 (n=3)
1-7 defects
Week 3 (n=5)
0-3 defects
30 days post
(n=6) 0-5
defects
60 days post
(n=12) 1-8
defects
90 days post
(n=15) 1-5
defects
Nov 2009-
July 2010
(n=22) 1-7
defects
2011 (n=7) 1-
8 defects
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Contact Info
Rita JankeQuality, Safety & Accreditation Leader – SHHC
Cathy MasudaQuality, Safety & Accreditation Leader – BCCH Specialty Medicine
Tracie NorthwayProject Manager, Strategic Implementation – BCCH & SHHC
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Questions???