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How to use this Standardized
Safe
Hand-off
Safe
Hand-oFF
Time to Toss the Scrap-Paper!
Get Standardized…..
80% OF SERIOUS MEDICAL ERRORS ARE RELATED TO MISCOMMUNICATION AT TRANSFER OF CARE.1
JACHO
The 2021 National Pateint Safety Goal
#2- Improving Effectiveness of Communication Among Caregivers. 2
DO YOU GET TIRED OF WRITING THE SAME "REPORT" INFORMATION
6,8,10+ TIMES A SHIFT?
This Standardized
Safe Hand-Off
originated and was refined
from the bedside
MISCOMMUNICATION
A 5 year study from Harvard6
(Data from 350,000 malpractice cases)
- 30% of Malpractice claims
- $1.7 Billion legal fees
- 32% Nursing cases involved 1 or more miscommunications
- 26% Surgery cases had 1 or more communication error
- 48% Ambulatory setting
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- Over 4,000 hand-offs/day in Teaching Hospitals.3
- ASPAN® Recommends Safe Hand-Off & Standardization tools, Practice Recommendation #6.4
- ASA Standard III, Upon PACU arrival pt is re-evaluated and verbal report provided to responsible PACU RN by the member of the Anesthesia team and the member shall remain in PACU until the PACU RN accepts responsibility of care.5
- The Joint Commisions Standardization tools and methods recommendations (forms, templates, checklists, protocols, Mnemonics, etc.) to communicate to recievers. Avoid only Electronic or paper format. 1
Laidlaw Vs LionsGate Hospital7
" The PACU is the MOST IMPORTANT room in the Hopital,"
- 23% Inadequate consent Communication
- 19% Provider miscommunication
- 13% Unsympathetic response to patient complaints
- 34% Resulted in high severity injury
- 14% Resulted in death
- Wrong site surgery
- Medication errors
- Delay in care
- Sentinel events
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Standardize Your
Hand-OFF
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Citations
1. Joint CommissionCenter for Transforming Healthcare. (2012, June 27). Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications. Https://Www.Jointcommission.Org/-/Media/Deprecated-Unorganized/Imported-Assets/Tjc/SystemFolders/Blogs/Tst_hoc_persp_08_12pdf.
2.The Joint Commission. (2021, March 25). National-patient-safety-goals. Joint Commission.Org. https://www.jointcommission.org/standards/national-patient-safety-goals/-/media/b35ba0b4b9754c6dbafdb1f86e152e5c.ashx.
3.Vidyarthi, A. R. (2004, March 1). Triple Handoff | PSNet. PSNet. https://psnet.ahrq.gov/web-mm/triple-handoff#.
4..American Society of PeriAnesthesia Nurses. Standards and Guidelines Committee & American Society of PeriAnesthesia Nurses. Standards and Guidelines Committee. (2020). 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. American Society of PeriAnesthesia Nurses.
5.American Society of Anesthesiologists. (2019, October 23). Standards for Postanesthesia Care | American Society of Anesthesiologists (ASA). Asahq.Org. https://www.asahq.org/standards-and-guidelines/standards-for-postanesthesia-care.
6.Harvard Medical Institutions Incorporated. (2015). Malpractice Risks in Communication Failures, 2015 ANNUAL BENCHMARKING REPORT. Https://Www.Rmf.Harvard.Edu/~/Media/0A5FF3ED1C8B40CFAF178BB965488FA9.Ashx.
7. Laidlaw v. Lions Gate Hospital, 1969 CanLII 704 (BC SC),
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