Building capacity to support human factors in patient

Building capacity to support human factors in patient

Building capacity to support human factors in patient safety Name of presenter Organisation Situation 80% of incidents are as a result of human factors.

Communication and team working are recognised to have significant impact on the quality of safe services for patients. Cavendish Review specified standards for support workers (Bands 1 4) working in all NHS and social care settings. Stephens Story Background

Health Education South West funded the West of England AHSN to develop an intervention using the SBAR tool (situation, background, assessment, recommendation) to support Human Factors training in patient safety focussing on support workers in community settings. Curriculum developed in partnership with Sirona Care & Health and North Bristol NHS Trust. Linked with Standard 6: Communication within The Care Certificate Standards. Assessment Human Factors Enhancing clinical performance through an

understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities, and application of that knowledge in clinical settings. Catchpole 2010 Human Factors Just a Routine Operation Recommendation SBAR Communication tools such as SBAR can greatly improve

team communication by making conversations more succinct with greater clarity of information and expectations of action required. They have been found particularly helpful in communications where staff are expressing concerns about deterioration in patient condition but can be used to structure any conversations (clinical and nonclinical, verbal or written) to ensure adequate, useful communications are given and expectations of actions are clear. S Situation patients /clients details, identify reason for this

communication, describe your concern B Background relating to the patient/ client, significant history, this may include medications, investigations/ treatments A Assessment what is your assessment of the patient/ client or situation, this can include clinical impression/ concerns, vital signs/ early warning score

R Recommendations be specific, explain what you need, make suggestions, clarify expectations, confirm actions to be taken SBAR in practice Handover primary care Escalation of unwell patient

Situation Identify yourself the site/unit you are calling from Identify the patient by name and the reason for your report Describe your concern Firstly, describe the specific situation about which you are calling, including the patient's name, consultant, patient location, resuscitation status, and vital signs.

For example: "This is Lou, a registered nurse on Nightingale Ward. The reason I'm calling is that Mrs Taylor in room 225 has become suddenly short of breath, her oxygen saturation has dropped to 88 per cent on room air, her respiration rate is 24 per minute, her heart rate is 110 and her blood pressure is 85/50. NHS Institute for Innovation and Improvement Safer Care Background Give the patient's reason for admission Explain significant medical history Overview of the patient's background: admitting diagnosis, date

of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. For this, you need to have collected information from the patient's chart, flow sheets and progress notes. For example: "Mrs. Taylor is a 69-year-old woman who was admitted from home three days ago with a community acquired chest infection. She has been on intravenous antibiotics and appeared, until now, to be doing well. She is normally fit and well and independent. NHS Institute for Innovation and Improvement Safer Care

Assessment Vital signs Clinical impressions, concerns For example: "Mrs. Taylors vital signs have been stable from admission but deteriorated suddenly. She is also complaining of chest pain and there appears to be blood in her sputum. She has not been receiving any venous thromboembolism prophylaxis.

You need to think critically when informing the doctor of your assessment of the situation. This means that you have considered what might be the underlying reason for your patient's condition. If you do not have an assessment, you may say: Im not sure what the problem is, but I am worried. NHS Institute for Innovation and Improvement Safer Care Recommendation

Explain what you need - be specific about request and time frame Make suggestions Clarify expectations Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the physician? Any order that is given on the phone needs to be repeated back to ensure accuracy. "Would you like me get a stat CXR? and ABGs? Start an IV? I would like you to come immediately

NHS Institute for Innovation and Improvement Safer Care Human Factors Awareness of human factors can help you to: Understand why healthcare staff make errors and in particular, which systems factors threaten patient safety Improve the safety culture of teams and organisations Enhance teamwork and improve communication between healthcare staff Improve the design of healthcare systems and equipment Identify what went wrong and predict what could go

wrong Appreciate how human factor tools can help to lessen the likelihood of patient/client/resident/tenant harm. Implementing SBAR in our organisation Available at e-do/enhancing-patient-safety/p atient-safety-priorities/human-fa ctors /

Contacts Local implementation lead contact West of England AHSN project lead Nathalie Delaney [email protected]

Recently Viewed Presentations

  • A01 (12 marks) A02 (12 marks) A03 (6

    A01 (12 marks) A02 (12 marks) A03 (6

    Both poets explore the way conflict is brutal and horrifying. 'War Photographer' features the sibilant phrase 'spools of suffering' - this tells us that the war photographer has travelled the world documenting conflicts, and he's now back in his dark...
  • Honors Warm-ups

    Honors Warm-ups

    Is it an acid or a base? pH=3 b) HNO. 3 c) tastes bitter d)Ca(OH) 2 acid . acid. base . base. 2) Can an acid be both weak and concentrated? Yes! Weak refers to an acid that only partially...
  • New Service Delivery Presented by Milton Russell New

    New Service Delivery Presented by Milton Russell New

    Times New Roman Lucida Sans Arial Copperplate Gothic Light Default Design Microsoft PowerPoint Presentation Microsoft Office Excel Worksheet Microsoft Visio Drawing New Service Delivery Presented by Milton Russell New Service Delivery Scope New Service Delivery Scope (cont.) Team Members Team...
  • Lenz'S Law

    Lenz'S Law

    LENZ'S LAW Heinrich F.E. Lenz Russian physicist (1804-1865) 1834 Lenz's Law There is an induced current in a closed conducting loop if and only if the magnetic flux through the loop is changing. The direction of the induced current is...
  • CH141 John Dalton  6 September 1766  27 July

    CH141 John Dalton 6 September 1766 27 July

    Credit Line: The Metropolitan Museum of Art, Purchase, Gift of James A. Moffett 2nd, in memory of George M. Moffett, by exchange, 1989 (1989.183) ... The Metropolitan Museum of Art, 1000 Fifth Avenue, New York, NY 10028, (212) 396-5050 (fax),...
  • Weathering


    Photo source: Acid rain: Burning coal, oil, and gas for energy produces pollution. This pollution combines with air and water, to create acid rain, and fast chemical weathering.
  • Click to edit Master title style - University of Oklahoma ...

    Click to edit Master title style - University of Oklahoma ...

    LECTURE SERIES ON BALANCE AND POSTURAL CONTROL IN INFANTS AND CHILDREN prepared for 2nd year Doctor of Physical Therapy students. ... Questions with multiple choice answers, ... Assessment methods. Levels of Achievement.
  • Medication Administration in the Community Administrative Rule 116

    Medication Administration in the Community Administrative Rule 116

    Communication is very important and must go both ways. It is best if the Nurse-Trainer remains, as much as possible in the teaching ,expert and supervisory role. The likelihood of staff communicating with you if you have termination responsibility is...