Teamwork, Communication and Patient safety Flashcards
What is the definition of interprofessional Teamwork?
“Members of different professions and/or agencies work with each
other and with patients/service users, to provide integrated health
and/or social care”
(Thomas, Pollard and Sellman 2014)
What percentage of patients experience preventable harm in the NHS?
5%
What percentage of errors in healthcare are related to poor communication?
70%
What has poor team work and communication been related to?
- Patient safety incidents
- Roots of 70% of reported adverse events
What does research from the USA suggest about poor communication by medical staff?
research from the USA suggest about poor communication by medical staff increases;
- Pressure sore rates by 46%
- Bloodstream infections by 42%
- Catheter-related infections by 54%
- Venous thromboembolism by 36%
What is the main root cause where communication has lead to adverse events?
Among staff (communication between each other)
What is an adverse/sentinel event?
An adverse event is an incident that results in harm to the patient. Adverse events commonly experienced in hospitals by patients over 70 include falls, medication errors, malnutrition, incontinence, and hospital-acquired pressure injuries and infection
What are 2 of the biggest communication issues in handover errors?
- Poor handwriting
- Verbal communication errors (52% of all reports) by Rabol et al 2011
What can we use to share patient information in a concise and structured format particularly in an emergency ?
SBAR handover
Explain the “Swiss cheese model”
The “Swiss cheese” model represents a series of barriers we put in place to prevent accidents and mishaps. Usually by chance we can avoid t
mistakes and never know about what could’ve happened as all the holes of the Swiss cheese hasn’t aligned and we cannot cause an accident
However occasionally the holes of the Swiss cheese aline perfectly and due to many failures we can cause an Accident which was preventable
An example is obtaining a patients allergies:
1) . Patients allergy history is not obtained by the history taker
2) . The prescriber writes an order for medication which the patient is allergic to
3) . The pharmacist fails to check patent allergy status
4) . The nurse gives the patient the drug which they are allergic to
5) . The patient goes into anaphylaxis, then cardiac arrest and dies
What is key to good patient care, patient safety and patient satisfaction?
Effective communication
What else is a key contributor to effective communication?
Intraprofessional team working
Who’s responsible of the patients safety and quality of care?
All members of the healthcare team
How do we minimise human error?
Tools exist to minimise human error in healthcare, however they are only as good as their ‘user/operator’
