Tools, techniques and taking action

• SBAR (select to show)

  There is good evidence to suggest that communication improves where the nursing handover is carried out using a structured reporting format, and the World Health Organization recommends the use of the SBAR tool to standardise handover communications.

  The SBAR process is straightforward and encourages you to focus on Situation, Background, Assessment and Recommendation. It can be used to:

  • Frame conversations requiring a clinician’s immediate attention and action.
  • Add clarity to an emergency call for advice about patient management.
  • Clarify what information should be communicated between members of the team and how to formulate it with the right level of detail.
  • Anticipate the information needed by colleagues and encourage assessment skills.
  • Develop teamwork and foster a culture of patient safety.

  A template for using SBAR when communicating about a patient to a clinical colleague in a hospital setting is provided by the NHS Institute for Innovation and Improvement. It describes the following.

  Situation

  • Identify yourself and the site/unit you are calling from.
  • Identify the patient by name and the reason for your report.
  • Describe your concern.

  Background

  • Give the reason(s) for the patient’s admission.
  • Explain significant medical history.
  • Provide information about the patient’s background from his or her records: admission diagnosis; date of admission; prior procedures; current medications; allergies; pertinent laboratory results; other relevant diagnostic results.

  Assessment

  This includes vital signs and clinical impressions and concerns. You need to think carefully when informing your colleague of your assessment of the situation, using your own observations and objective indicators such as laboratory results. Note that in the absence of objective data to support your concerns, it is acceptable to say something like: “I'm not sure what the problem is, but I am worried”.

  Recommendation

  • Explain what you need, being specific about your request and the time frame in which it should be delivered.
  • Make suggestions for next actions.
  • Clarify expectations of what outcomes can be achieved.
  • Ensure any order given over the phone is repeated to ensure accuracy.

  Research by Christie and Robinson has shown that using the SBAR tool improves communication between nursing teams and helps reduce missed episodes of care and adverse patient outcomes. Teams who have worked with SBAR recommend the following as useful prompts to use the tool:

  • Notepads, paper and pocket cards with the tool printed on them.
  • Stickers on or next to telephones to act as a visual prompt.
  • SBAR information included in competency documents, induction packs and introduction materials for temporary staff.
  • An SBAR sticker or note in the patient records as a marker of the communication.

  It is also important to ensure people feel comfortable about prompting each other to use the tool, and to disseminate good practice to other teams by modelling communication behaviour based on SBAR.

• Incident decision tree (select to show)

  The NPSA has developed a web-based incident decision tree tool that will support health care managers and practitioners to move away from attributing blame for an untoward incident or event and instead finding the cause when things go wrong.

  Systems failures, rather than individual error, are often the root cause of incidents that threaten patient safety. Despite this, the default position for many health care organisations when a serious patient safety incident occurs tends not to be to explore the system-related factors that may have contributed to the incident, but to suspend, investigate and then possibly discipline the individual member(s) of staff involved. Not only is this potentially unfair to staff, but it’s also potentially unfair to patients, as it may divert senior management attention from significant system failures that are putting patients at risk.

  The NPSA Incident Decision Tree tool can help managers and practitioners:

  • Decide whether it is necessary to suspend staff from duty following a patient safety incident.
  • Explore alternatives to suspension, such as temporary relocation or modification of duties.
  • Consider other possible measures to be taken as the investigation progresses.

  The incident decision tree tool can be used in parallel with the root cause analysis toolkit. You can find links to these tools in the 'Useful resources' section.

• Root cause analysis (select to show)

  Root cause analysis, which is similar to critical incident analysis, is a technique health care managers and teams can use to try and establish what went wrong and why.

  It enables them to get to the “root” of the problem through a series of systematic questions focusing on environmental and process issues related to an untoward incident or near-miss. The aim is that this will identify possible causes and indicate potential solutions.

  The NPSA has developed a root cause analysis toolkit that enables users to:

  • Understand what a root cause analysis investigation is.
  • Develop appropriate knowledge and skill to play a part in a root cause analysis investigation.
  • Develop a causal-based approach to the analysis of issues and problems that threaten patient safety, rather than one of blame.

  Significant event audit is essentially a primary care equivalent of root cause analysis. You can find out more about significant event audit and access relevant tools and guides on the NPSA website - links are provided in the 'Useful resources' section.

• Intentional rounding (select to show)

  Intentional rounding is a process though which hospital nurses, those working in community and care home staff can ensure individual patients are checked and cared for at regular intervals.

  The process is structured so that it follows a consistent pattern. It typically begins with the nurses or carers introducing themselves to the patient and explaining why they are there. It is suggested that this enables the nurses or carers to engage or “connect” with the patient, putting him or her at ease and increasing confidence.

  There then follows a systematic approach to carrying out regular, scheduled tasks, which includes taking observations, checking pain and comfort levels, supporting the patient to mobilise, offering a drink and nutrition, enquiring about toilet needs and making sure the immediate environment is clean, tidy and safe. Any “unscheduled” needs – a patient feeling particularly anxious, for instance – can also be addressed at this time.

  At the close of the encounter, the nurses or carers will invite the patient to indentify anything else that needs to be done, with an assurance that they have time to respond appropriately. Following this, the nurses or carers will give the patient an approximate time when they will return and record the care given and observations made.

  Intentional rounding supports patient safety by ensuring all patients receive attention on a regular basis. This means that potential problems and risks are liable to be spotted earlier, and that omissions in care and “missed care” episodes become less likely.

• VOCABULARY (select to show)

  VOCABULARY is an acronym that can be used to underpin your approaches to promoting patient safety. It can be a useful tool to keep in mind when conducting a comprehensive patient safety evaluation of your clinical area. The focus is on:

  • Values: using the values and principles of nursing to support the values and principles underpinning patient safety
  • Observation: developing your awareness of what is going on in your organisation and understanding how patient safety tools can enhance observation
  • Communication: including active reporting of safety issues and incidents to increase understanding and promote positive action
  • Action: embedding a patient safety consciousnesses as an underpinning element of your practice and your organisation’s activity, and promoting continuity of care
  • Blindspots: tackling denial and blame cultures
  • Unlearning: using tools to help move people on from complacent and potentially dangerous attitudes to patient safety and reducing complexity in patient safety
  • Learning: being open to experience and evidence that supports patient safety
  • Agenda: using tools to ensure patient safety is central to service delivery
  • Risk: using tools to increase individuals’, teams’ and organisations’ risk awareness and competence
  • You: developing your own accountability and responsibility for reducing risk, responding to events, learning from experience and using appropriate tools.

• Principles of Nursing Practice (select to show)

  The Royal College of Nursing worked in partnership with the Department of Health, Nursing and Midwifery Council (NMC) and patient and service user organisations to develop the Principles of Nursing Practice, which describe what everyone can expect from nursing practice, whether colleagues, patients, their families or carers.

  The principles focus on eight nursing practice issues. Principle C, Safety, has a clear and obvious link to the patient safety agenda, but each of the others also has a significant impact on safety and quality:

  • Principle A: dignity, humanity and equality
  • Principle B: accountability and responsibility
  • Principle D: person-centred care
  • Principle E effective communication
  • Principle F: applying skills and knowledge
  • Principle G: continuous care across teams
  • Principle H: leadership and responsive care.

  You will find a link to the Principles of Nursing Practice in the 'Useful resources' section.

• Patient Safety Thermometer (select to show)

  The Patient Safety Thermometer was developed by Safety Express, the QIPP (Quality, Innovation, Productivity and Prevention) safe care work stream in the NHS in England, in partnership with other relevant stakeholders. It is described as “a tool for measuring baseline information about risk assessment, risk management and outcomes for each of the four harms” (pressure ulcers, falls, urinary infections and catheters, and venous thromboembolism).

  The Patient Safety Thermometer is a minimum data set that teams are invited to maintain through the use of “safety crosses”. Safety Express claims that the advantages of the tool include the ability to:

  • Survey harm at the level of the individual patient while the patient is still in the care setting.
  • See improvement over time within a care setting.
  • Raise awareness about the individual harms and identify the proportion of patients without harms.
  • Raise frontline teams’ awareness of key risk assessments, management plans and outcomes.
  • Sample 50% of patients and clearly determine how long the survey will take, readily analyse and graph data at the press of a button (Safety Express, 2011).

  You can access links to the Patient Safety Thermometer and how to use it in the 'Useful resources' section.

When you have completed all the sections in this learning resource, you should have a deeper understanding of the issues relating to patient safety. You may also be forming some ideas about how you can make changes that will improve patient safety in the care you provide and the routines in your work setting. The two resources provided below are PDF documents and will help you to plan how you will action the learning you've gained in this learning opportunity - see [how to access PDF files].

Select the link to My action plan (PDF 27KB) to identify key actions you have identified that you want to implement. Your action plan is a PDF document and can be saved on your computer and uploaded to your e-Portfolio as evidence of your learning. You may also want to discuss it with your colleagues or your manager.

You may also wish to write a reflective statment about your learning for your e-Portfolio and PREP. Select the link to the Reflective record template (PDF 42KB) for a useful proforma to help you write your statement.