Culture, Technology and Communication key to Patient Safety
Substandard care is not something anyone sets out to deliver to patients, but nevertheless it has happened. Human, systemic or a combination of both factors have been attributed as causes in both situations investigated by the Kirkup and Francis reports. The key question is how to ensure it doesn’t happen in the future.
On a recent #NurChat twitter chat, nurses, clinicians and patient safety leads shared their thoughts on patient safety, never events and collaborative working. The three common themes surrounding patient safety that emerged in the discussion were culture, technology and communication.
Culture was highlighted as an important part of facilitating the escalation of concerns relating to a patient’s condition. A supportive culture working in the best interests of patients should encourage staff to raise concerns when necessary in the knowledge that they will be considered. However, a pathway of escalation is only effective with adequate staffing levels of suitably qualified staff.
Staffing levels are a concern for several #NurChatters, who felt that they play a crucial part in the reduction of errors, not only in primary care but also in the community.
With observations often recorded digitally, technology can support the identification of a deteriorating patient with alerts triggered when their measurements deviate from their baseline. Automatic escalation can be programmed, but it should only be viewed as a prompt as nothing can replace clinical assessment and judgements. Another example of positive use of technology was the use of an app to gather feedback from patients in real time and allow senior staff, such as ward sisters, to respond accordingly.
Universal communication between different healthcare teams is essential for coordinated care. SBAR assessments (Situation, Background, Assessment and Recommendation) were highlighted as a unifying communication across healthcare teams to deliver info on patient status.
The use of team huddles and de-briefing following an incident were also highlighted as valuable tools in effective communication. However, accurate record keeping and documentation are essential to this process in order to provide a clear audit trail and therefore valuable feedback for those involved. Many also expressed an interest that the newly-announced Independent Patient Safety Investigation Service (IPSIS) will lead training and sharing of information in relation to patient safety after it launches in April 2016.
Join #NurChat on Tuesday 4th August when the conversation about technology in nursing will be looking at how far is too far.