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Stanford Medicine Newsletter Updates For the Local Community


Filling the communication gap

New standards set for patient transfers

Teamwork and clear communication are streamlining patient transfers for Stanford Hospital & Clinic nurses (from left) Angeli Danao, RN; Carolyn Cabrera, RN; and Stephanie David, RN.


Every time a patient moves from one part of the hospital to another or leaves the hospital to go to another care facility, it’s critical that the patient’s medical information is effectively communi-cated from one caregiver to another. Often, however, that is not the case: Studies estimate that as many as 80 percent of preventable errors begin with poor communication among caregivers.

Now Stanford Hospital & Clinics is taking the lead nationally in finding ways to improve that communication. It is one of 10 hospitals enlisted a year ago by the Joint Commission to find out why patient information isn’t always shared adequately and to come up with answers and solutions.

“Time and time again, we’ve found problems with hand-offs at the heart of safety and quality problems at our institution,” said Kevin Tabb, MD, chief medical officer at SHC. Working with the study group “has been particularly valuable to make sure we learn from each other’s suc-cesses and failures. There are a fair number of different types of hospitals represented here, yet everybody is facing similar issues.”

As a result of the effort, the hospitals in the study group have been able to cut in half the number of deficient communications in patient hand-offs, according to a study announced re-cently by the Joint Commission, the accrediting agency for U.S. hospitals.

Establishing guidelines

The study found that failed hand-offs were the result of many factors, though the most common in-volved lack of teamwork or respect between the senders and receivers, or differing expectations about what information should be conveyed. Some communication failures also were a result of dis-tractions, competing priorities or lack of a standardized method for passing along information.

At Stanford, the study focused on transfers of patients in intensive care units. Both physicians and nurses were involved in identifying the problems in hand-offs and in brainstorming possible solutions.

as differences in expectations. For instance, caregiv-ers handing off the patients thought the relevant patient information could be retrieved in Epic, the hospital’s online medical record system. However, those receiving patients may not have had the time to read the patient’s entire medical record and simply expected a concise summary of the patient’s condition.

“The key to leveling expectations was standardizing what information needed to be shared and implementing guidelines for verbal hand-off,” said Nancy Szaflarski, PhD, RN, the hospital’s program director for quality outcomes.

Program improvements

As the program is rolled out from the ICUs to the rest of the inpatient units, transfers now include a verbal exchange of information—face-to-face, when possible. “People need to be able to ask questions,” said Christine Thompson, RN, MSN, the clinical nurse specialist who is leading the implementation process for the nursing staff.

Another change is geared toward avoiding patient transfers during shift changes. That means a primary nurse will always be the person transmitting the information. Back-up coverage is made available if needed so that the primary nurse can do the hand-off. In addition, three specific screens in Epic have been identified as containing the most relevant information about a patient at the point of transfer. More phones have been added to units to make communication easier.

Work will continue, of course, to perfect hand-offs. “We identified 39 steps and certain points that make up the hand-off process,” Thompson said. “It was a real eye-opener.”

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