Download Case Study #1

Improving Patient Safety in LongTerm Care Facilities:
Communicating Change in a
Resident’s Condition
Student Version
A Safe Environment
Effectively communicating change
in a resident’s condition is critical to
patient safety.
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Case Study #1
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Ms. Malone
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Creating a Safe Environment
• Reporting changes helps keep resident’s safe.
• Learning and experience are what make safety
•
•
possible.
Openly reporting anything that might affect a
resident’s well-being is essential for a safe
environment.
Change in a resident’s condition should be
reported openly whenever it happens.
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Key Principles of Effective
Communication
• Teamwork
• Open reporting
• Reporting unwanted
•
events
Giving and receiving
information
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Teamwork
• Report change across the
•
•
care team.
Work together to identify
what the change may
mean.
Take action as a team.
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Reporting Unwanted Events
• Learn to communicate
•
•
promptly and openly when
something happens that
might affect a resident’s
well-being.
Move beyond blaming
anyone to being able to
openly share experiences.
Show you care by
speaking up.
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Giving and Receiving Information
• Express information in a way that will be
•
•
understood by others.
Hear information as it is being reported.
Make effective use both of verbal and nonverbal
communication skills.
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Barriers to Communication
• Gender
• Age/generation
• Language
• Culture
• Status
• Interpersonal issues
• System barriers
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Case Study #2
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Case Study #2
Mrs. Brown
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Case #2
Min-Wa and Susan
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Case Study #2
Observations
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What Should Be Communicated?
•
Physical changes
► Walking
► Urination/bowel patterns
► Skin quality
► Level of weakness
► Falls
► Vital signs
•
•
Nonphysical changes
► Demeanor
► Appetite
► Sleep
► Confusion
► Agitation
► Pain
Relevant external factors
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How Should Information Be
Communicated?
• Reporting and communication tools:
► Early
Warning Tool
► SBAR
► CUS
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Stop and Watch Early Warning Tool
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SBAR Tool
SBAR:
http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Communication%20Tools/
Communication%20Within%20the%20Nursing%20Home/INTERACT%20SBAR%20Form%
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20v8%20Jan%2014%202013.pdf
Case Study #3
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Case Study #3
Mr. Harris
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Case #3
Observations, Day 4
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Case Study #4
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Case Study #4
Change-of-Shift Meeting (Min-Wa)
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The CUS Tool
• I am Concerned
•
•
about my resident’s
condition.
I am Uncomfortable
with my resident’s
condition.
I believe the Safety of
the resident is at risk.
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Principles in Action
CUS: Min-Wa to RN Team Leader
• I'm concerned about Mr. Harris.
• I’m uncomfortable that his temperature is up and
•
that he has developed diarrhea.
I believe that he might be developing an
infection that should be treated.
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Case Study #5
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Case Study #5: Mrs. Carver
February 2012 – March 2014
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Case Study #5: Mrs. Carver
April 1, 2014
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Case Study #5: Mrs. Carver
April 2, 2014
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Key Points
• Communicate changes promptly.
• Reports of change can come from many
sources.
• Every team member is responsible for reporting
changes.
• Everyone faces barriers to communication.
• Tools to break down barriers.
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