Poster Presentation

Friday, July 13, 2007
9:30 AM - 10:15 AM

Friday, July 13, 2007
3:15 PM - 4:00 PM
This presentation is part of : Poster Presentation III
Promoting a Safe Patient Hand-Off Using an Electronic Medical Record
Janet Gilmore, MSN, RN, Perioperative Services, The Methodist Hospital, Houston, TX, USA
Learning Objective #1: understand how the electronic medical record is used to produce a crystal report for standardizing a patient hand-off document using the SBAR methodology.
Learning Objective #2: understand how the electronic medical record may save time while improving the transfer information required for a safe patient transfer.

Joint Commission on Accreditation of Health Care Organizations (JCAHO) introduced a new National Patient Safety Goal for 2006 to implement a standardized approach to “Hand-Off” communication. The vision of The Methodist Hospital is to be the world leader for safety in patient care by 2010.  With that in mind, SBAR (Situation, Background, Assessment and Recommendation) was adopted as the standard of communication for moving this vital goal into compliance.

Challenged with numerous detailed reports required before a patient can be transferred to a nursing unit, the Post Anesthesia Care Units (PACU)  enlisted the assistance of Information Technology (IT), to design a comprehensive report that is sent electronically to the nursing units prior to sending the patient. The tool is created by extracting information from the PACU electronic medical record, creating an electronic report using the SBAR methodology that it is sent directly to the receiving unit’s printer. A follow-up phone call is made to the receiving unit that confirms receipt of the report and allows for the requisite opportunity for questions to occur.

Prior to this technology, being placed on hold, waiting for the busy nurse to answer the phone wasted many hours each day.  Previous to this process, information was shared verbally and is now shared in an electronic fashion. The receiving unit now has the distinct advantage of a written document for reference and that information may now be shared with colleagues on the same shift or at shift change.