Unit 3 Health-Care Team Communication

1. Unit 3 Health-Care Team Communication Group Processes and Patient-Safe Communication Among Team Members

2. Chapter 12 Patient Safety Communication Risk Factors in Nursing Work Systems

3. Communication Failures Result in Patient Harmful Events • Nurses must: • Learn how communication failures happen • Recognize risks for communication failure in the work environment • Use patient-safe communication strategies specific to working as a member of the health-care team • Advocate for health-care system improvements to keep patients safe

4. Communication is crucial to prevent harmful events in the nurses professional role • Patient Monitoring • Ongoing assessments and evaluation of patient health state to maintain situational awareness, with the need for communication with team members for clinical decision making • Health-care providers form a mental model of the patient’s clinical situation and make clinical decisions based on the nurse’s shared essential information • Coordination of Care • Communicate to coordinate patient care and services from multiple members of the health-care team • Maintaining Continuity of Care During Transitions • Communicate patient status and plan of care across care continuums

5. The Institute of Medicine Report • 44,000 –98,000 deaths occur as a result of medical errors • One death every 5 – 10 minutes • Nearly 70% of these deaths related to communication failures • Cost associated with medical errors is $8–$29 billion annually • Since 2000, when the report was published, little progress has been made to reduce the numbers of harmful events

6. Reducing Patient Care Errors:Systems vs Personal Approach • Systems approach • Recognizes people are fallible and make mistakes • Does not hold professionals accountable for system failures • Does not tolerate gross misconduct of individual • Personal approach • Blames, names, shames, and retrains individuals committing errors • “Bad” people make errors Health-care organizations are slow in adopting a systems approach

7. Failed communication is the reason for nearly 70% of Sentinel Events

8. Why Do Errors Occur? System Approach • Faulty health-care systems • Faulty processes within health-care systems • Poor working conditions • Lead individuals to make mistakes • Not the result of individual recklessness of health-care providers • Health-care system is the problem and needs to be made safer

9. Health-care errors are symptoms of an unsafe system • Conditions within the nursing work system affect human performance leading to patient-care errors • More acutely ill patients • Shorter hospital stays • Frequent patient turnover • Extended hours and overtime • Stressful work environment • Interruption-driven environment • High nursing workloads

10. Health-care team members will improve safety by taking a systems approach: • Understanding system design and the impact on safety • Risk awareness through anticipating and recognizing safety problems • Correcting safety problems to prevent harm to patients

11. Systems approach requires knowledge of human factors science • Study of the “fit” between people, • The things they do • The objects they use • The environments in which they work. • If a good “fit” is achieved, it reduces stress on people

12. Human Abilities and Limitations Affecting Performance • Human strengths • Creativity • Adaptability • Flexibility • Good at finding explanations and meanings from ambiguous evidence and developing a work-around or “quick fix” when things do not work as well as desired • Human weakness: Humans make errors • 90% of all organizational accidents result from human error • Human error is the failure of a planned action to achieve its intended goal • Humans are fallible: • Cannot maintain continual alertness • Inability to attend to several things at once • Have habits of thought and action • Lack precision in mental functioning

13. Normal Cognition Theory: How People Think During Performance of Activities • Automatic mode—often repeated, routine tasks • Conscious mode—conscious critical thinking in new situations • Mixed mode—during trained-for situations

14. Types of Human Errors • Errors of Execution • The plan is adequate but does not proceed as intended • Skill-based error—attention or memory failures • Errors of Decision Making • The wrong plan is used to achieve an aim • Rule-based error— apply the wrong rule to a patient situation • Knowledge-based error—lack of knowledge, lack of information or misinterpretation • Violations • Deliberate deviations from standard practices, policies, and procedures • People purposely break rules with poor operating procedures, inadequate work environments, low morale, time pressures, and inadequate tools and equipment causing frustration

15. The Nursing Work System • System defined: Interdependent components that interact to achieve a common goal • Nursing work system: Interdependent components of the health-care system • Levels of hierarchy: • Higher levels provide context for lower levels (context = policies, procedures, norms, technologies, physical environment, people) • Changes at one level affect all other levels, affecting individuals, groups, or the organization • Higher-level decisions can exert influence that unexpectedly contributes to work conditions that lead to human error

16. Concept Map of the Nursing Work System

17. The Nursing Work System • Performance inputs—guide the nursing work system • Process—changing inputs into outputs through human behavioral performance • Performance outputs—outcome of the inputs and process • System inputs influence nurses’ ability to perform work activities that will affect patient outcomes • A well-functioning system can facilitate performance • A poorly functioning system creates conditions that lead to human errors

18. How System Factors Create Hazardous Conditions • Accident Causation Theory • When system components across levels function well together, they collectively serve as barriers to prevent harmful events • E.g., adequate staffing and appropriate workloads • When weaknesses in the system interact in a way to breach barriers, harmful events occur • E.g., inadequate staffing and heavy workloads

19. System Defenses as “Swiss Cheese” • System defenses have many holes • These holes continually open, close, and shift • Harmful events happen when the holes in many successive system levels momentarily line up and propel a trajectory of error leading to a harmful event

20. Model of the Swiss Cheese Nursing Work System

21. System defense holes occur for two reasons • Active failures—unsafe acts that are human errors • Attention slips • Memory lapses • Honest mistakes • Intentional violations • Latent conditions—flaws within the work system due to decisions made by managers and top-level administrators • Poorly designed facilities • Training gaps • Staff shortages • Heavy workload • Inadequate communication processes • Faulty policies and procedures

22. Mental Antecedents to Active Failures and Unsafe Acts • What goes on in the mind of the health-care provider prior to an active failure with an unsafe act • Distraction, momentary inattention, forgetting, losing the picture, preoccupation, fixation • Environment can be hectic, demanding, time-pressured, and inadequately staffed

23. Systems Approach: Focus on Latent Conditions • Determine underlying cause for active failures • Focus on changing conditions in the system that contribute to human error • Nurses who have the greatest contact with patients are positioned to detect and correct health-care errors before they reach the patient • Nurses must speak assertively about latent conditions • Nurses must develop situational awareness of the high-risk environments in which they work

24. Nurses must identify and correct latent conditions in the nursing work system • Unworkable procedures • Unrealistic policies • Design deficiencies in nursing work areas • Error-provoking conditions leading to unsafe acts (overburden human limitations) • Time pressures • Heavy workload • Understaffing • High cognitive demands • Interruptions • Long hours • Inadequate training • Unavailable essential information • Inadequate communication processes