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Learning Objective 1: The learner will be able to discuss standardized communication's effect on patient safety.
Learning Objective 2: The learner will be able to discuss the impact of applying research to nursing practice and patient safety.
Abstract
Purpose. The Transfer of Care bundle outlines a standardized process for safe patient hand-off communication. Hand-off communication includes nurse-to-nurse at the change of shift, while transferring a patient to another unit, or to another licensed individual.
Background. LMHS employed two independent consulting firms to complete safety audits for the system. The first audit was completed in 2008, the second in 2009. Nurse-to-nurse communication was a major concern in both audits. Anytime patient care is transferred from care team member to another, there is risk pertinent information about the patient is not communicated. Any lapse in communicating patient information compromises patient safety. The literature review findings trends are standardization is critical for both communication process and elements. Standardization improves hand-off communication efficiency and accuracy.
Methodology. Staff nurse representatives from units throughout the system completed an extensive literature review; resulting in the development of the Transfer of Care bundle. The bundle outlines the process for nurse-to-nurse communication and the PASS ME SAFELEE acronym for required elements to communicate. An education and implementation plan was developed and tested on seven Phase One units.
Findings. Patient satisfaction scores, nursing report satisfaction surveys, and staff reporting of good catches will measure the effects of the bundle. Patient satisfaction scores and report satisfaction survey scores are recorded and trended on a scorecard. Results have shown continuous improvement on all Phase One units for patient satisfaction and nursing report satisfaction.
Implications on practice. The Transfer of Care bundle standardizes what information is communicated and the process of information sharing. Compliance with the bundles increases patient safety when nurses are transferring care of the patient to another nurse.
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