joint commission- sbar pt1- oct10

Effective Handoff Communication Part 1Developing and Implementing New SBAR Tool

Simplicity is the ultimate sophisticationmdashLeonardo DaVinci

It makes so much sense In a singleorganization why have differentprocesses for performing the same func-tion Would it not be simpler to have allcaregivers on the same page so to speak While standardization of patient

handoff processes sounds like a simplesolution many organizations around theworld continue to struggle with imple-menting a single standard process thatcan be used for every handoff in theorganization Instead many health careorganizations find themselves in thepredicament of having different depart-ments or staff members using disparatehandoff methodologies At times evenwithin the same department the nursingstaff can have one process for conductinghandoffs while physicians have anotherWhile working in the Department of

Surgery of CHRISTUSreg St VincentRegional Medical Center in Santa FeNM I developed a poor manrsquos tooldesigned to help implement a standard-ized handoff process I achieved this byusing a model of structured communica-tion known as ldquoSBARrdquo (See the tool inFigure 1 on page 3) SBAR is an acronymfor Situation Background Assessmentand Recommendation The US Navy

originally developed SBAR for use onnuclear submarines Later staff at KaiserPermanente adapted the process to applyto handoffs in health care These innova-tors were Michael Leonard MDphysician leader for Patient Safety DougBonacum MBA CPHQCPHRM vice president for safetymanagement and Suzanne GrahamRN PhD director of Patient SafetyCalifornia Region1 (See the SBAR pocketguide in Figure 2 on page 4)

CONTENTS

Effective Handoff

Communication Part 1

Developing and Implementing

New SBAR Tool 1

Patient Safety Pulse

Your Patient Safety News

Joint Commission Announces

Changes to NPSG010301 2

Moving Your Hospital to a

New Facility Part 1

The Planning Phase 6

Home Oxygen Therapy

Complying with NPSG150201 9

wwwjcrinccom

The Joint Commission

Perspectives on Patient Safety TM

October 2010 Volume 10 Issue 10

Michael S Woods MD MMM

(continued on page 3)

By Michael S Woods MD MMM

wwwjcrinccom

Patient SafetyPulseYour Patient Safety News

Joint Commission Announces Changes to

NPSG010301

2 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY October 2010

Top 5 in the News

Senior Editor Jim ParkerProject Manager Bridget ChambersManager Publications Helen M Fry MAExecutive Director of Publications

Catherine Chopp Hinckley PhDContributors Meghan Pillow RN

Rachel Brickman Levin

Subscription Information The Joint Commission Perspectives on Patient SafetyTM (ISSN 1534-5181) is published monthly(12 issues per year) by

Joint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace IL 60181

Send address corrections to The Joint Commission Superior Fulfillment131 West First StreetDuluth MN 55802-2065

Annual subscription rates for 2010Domestic $319 for print and online $299 foronline only international $410 for print and on line$299 for online only Back is sues are $25 each(postage paid) To begin your subscription call800746-6578 fax orders to 218723-9437 or mailorders to Joint Commission Resources 16442 Col-lections Center Drive Chicago IL 60693

Editorial policy Reference to a name an organization a product or a service in The Joint Commission Perspectives on Patient SafetyTM

should not be construed as an en dorsement byJoint Com mission Resources nor is failure toinclude a name an organization a product or aservice to be construed as disapproval

copy 2010 by The Joint Commission No part of thispublication may be reproduced or transmitted inany form or by any means without written permis-sion

Joint Commission Resources Inc (JCR) an affiliate of The Joint Commission has been designated by The Joint Commission to publishpublications and multi media products JCR reproduces and distributes these materials underlicense from The Joint Commission

Visit us on the Web at httpwwwjcrinccom

1Disclose Errors Health care organi-

zations should disclose medical

mistakes that affect multiple patients

even if patients were not harmed by

the event according to the Agency for

Healthcare Research and Quality

2Vaccination Up Among Teens

Increases of as much as 15 percent

were made in nationwide coverage for

vaccines among 13- to 17-year-olds

according to 2009 National

Immunization Survey-Teen estimates

recently released by the Centers for

Disease Control and Prevention

3JCR Vaccine Challenge Begins

Joint Commission Resources has

launched its 2010ndash2011 Flu

Vaccination Challenge to promote

health care worker vaccination

During the 2009-2010 flu season the

Flu Vaccination Challenge yielded an

average immunization rate of 76mdasha

13 increase over the rate reported in

2008ndash2009 and 27 above the

national average Visit wwwjcrinccom

fluchallenge for more information

4Patients Skip Care Due to Cost

According to a Deloitte Center for

Health Solutions survey 79 of 4008

patients surveyed visited a physician

or health professional in the previous

year down from 85 in 2009 More

than 40 of all respondents said they

delayed care because of cost

5New Patient-Centered Care

Resource The Joint Commission

has released a new monograph on

patient-centered care and communica-

tion The monograph is available for

free download at The Joint

Commission Web site at

httpwwwjointcommissionorg

PatientSafetyHLC

The Joint Commission has approved revisions to NPSG010301 EP 1 Theserevisions were approved subsequent to the publication of the September 2010special National Patient Safety Goals issue of Perspectives on Patient SafetyNPSG010301 requires accredited organizations to ldquoEliminate transfusion

errors related to patient misidentificationrdquo The requirement applies to ambu-latory care organizations hospitals critical access hospitals and office-basedsurgery practices The revised element of performance reads as follows 1 Before initiating a blood or blood component transfusion

bull Match the blood or blood component to the orderbull Match the patient to the blood or blood componentbull Use a two-person verification process or automated identificationtechnology such as bar coding

(See also NPSG010101 EPs 1 and 2)Before these revisions the language regarding ldquoautomated identification

technologyrdquo in the third bullet point was contained in a note This revision iseffective immediately Research indicates that most transfusionndashrelated errors occur because a

blood sample for laboratory testing is mislabeled or a patient isnrsquot properlyidentified at the bedside before a blood transfusion begins1

References1 Linden J et al Transfusion errors in New York State An Analysis of 10 yearsrsquo

experience Transfusion 401207ndash1213 2000

PS

This is the first of two articles thataddress safe and effective handoff com-munications This article discusses therisks associated with patient handoffsand the aforementioned tool The sec-ond article will discuss strategies fororganizationwide standardization ofhandoff processesFor any patient safety initiative a

commitment by all stakeholders to sup-port a culture of safety and willingnessto address system failures is absolutelynecessary2 To build a strong safety cul-ture the following four elements mustbe implemented2

1 Development of a sense of trustamong all stakeholders and caregivers

2 Dissemination of information to alllevels or managers and employeesand ensuring that the message iscommunicated

3 Development and support of aproactive approach instead of a reac-tive approach

4 Commitment to a culture thatplaces safety as the first priority

I would like to especially emphasizethe word trust in item one abovebecause the basis for trust is communi-

cation3 In other words safe patientcare like SBAR is grounded in effec-tive communication and is the engineof trust between providers and patientsAn organization that is committed toeffective communication can result in aculture suffused with trusting relation-ships out of which naturally ensues aculture of safety that benefits allpatient-care activities All members ofthe patient-care team should under-stand that they are responsible for clear unambiguous communication in order to maximize positive patient

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY October 2010 3

Effective Handoff Communication Part 1

(continued from page 1)


Figure 1 Handoff Communication Tracking Sheet

safety outcomes Furthermore theyshould be held accountable for comply-ing with patient-safety policies andprocedures designed to support effec-tive interactions including thoseassociated with patient handoffs

Handoffs A Risky BusinessThe Joint Commission defines handoffas ldquothe real-time process of passingpatient-specific information form onecaregiver to another or from one teamof caregivers to another for the purposeof ensuring the continuity and safety ofa patientrsquos carerdquo4 In 2006 in order toguide health care organizations throughthe process of improving handoff com-munication processes The JointCommission created National PatientSafety Goal 2E (later renumbered asNPSG020501) As of January 1 2010 handoff

communications transitioned out ofthe National Patient Safety Goals andinto Standard PC020201 Element ofPerformance 2 ldquoThe hospitalrsquos processfor handoff communications providesfor the opportunity for discussionbetween the giver and receiver ofpatient informationrdquo According to The Joint Commissionrsquos

Sentinel Events Database communica-tion breakdowns are a contributingfactor in 65 of sentinel events thenumber one driver of all root causes in

the database5 (Note that the SentinelEvents Database information is col-lected through voluntary reporting andrepresents a small percentage of actualevents)A 2006 survey of resident physicians

at Massachusetts General Hospital alsofound that handoffs often lead topatient harm More than half of the161 medical or surgical residents whoresponded to the anonymous surveysaid they recalled at least one occasionin their last month-long rotation whena patient suffered from flawed hand-offs About one in nine said the harmthat resulted was significant6 In thisstudy problematic handoffs weredefined as having inaccurate incom-plete or missing information Thesurvey took place before the hospitalhad begun using its formal electronicsign-out tool Almost all the residentssaid the handoffs were face-to-faceAlmost half said they rarely occurred ina quiet setting and more than one

third said they were interrupted at least once These obstacles put patientsat risk6

Ineffective handoff processes canhave serious consequences includingthe following7bull Adverse events delays in medicaldiagnoses and treatment andredundant communications

bull Redundant activities such asadditional procedures and tests

bull Lower provider and patientsatisfaction higher costs longerhospital stays more hospitaladmissions and less effectivetraining for health care providers

Passing the Torch Not theBuckBoth the giver and receiver of patientinformation have important responsi-bilities for ensuring effective handoffsand each party must be comfortablewith the information exchange Thehandoff is not a quick down and dirty

Patient Safety Editorial Advisory Board

wwwjcrinccom4 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY October 2010

Bonnie M BarnardMPH CIC QualitySpecialist St PeterrsquosHospital Helena Montana

Hedy Cohen RN MSVice President Institute forSafe Medication Practices

Kathy Connolly RNMSEd CPHRMAssistant Vice PresidentRisk Management PremierInsurance ManagementServices Inc

Nilda Conrad MBACPMSM CPCSPresident NationalAssociation of Medical StaffServices

Diane D Cousins RPhNational Quality ForumrsquosExpert Panel

David Fuller Senior SpaceSystems and OperationsEngineer and AssociateFellow of the AmericanInstitute of Aeronautics andAstronautics

Suzanne Graham RNPhD Director of PatientSafety California RegionsKaiser Permanente

Robert S Lagasse MDVice Chairman Departmentof Anesthesiology AlbertEinstein College of Medicineamp Montefiore MedicalCenter New York

Jeannell M Mansur RPhPharmD FASHPPractice Leader MedicationSafety Joint CommissionResources

David Marx Head of thePaediatric GastroenterologyTeam University HospitalCzech Republic

Deborah Nadzam PhDRN FAAN DirectorInternational Quality andPerformance MeasurementJoint CommissionResources

Rita Shane PharmDFASHP DirectorPharmacy Services andAssistant Dean ClinicalPharmacy UCSF School of

Pharmacy Cedars-SinaiMedical Center Los Angeles

Paula Spears DNScRN Corporate DirectorProfessional Practice andAdvancement Methodist LeBonheur HealthcareMemphis

Sherry Umhoefer RPhMBA Vice PresidentQuality and ComplianceMcKesson MedicationManagement


(continued from page 3) Figure 2 SBAR Pocket Guide

exchange of a few facts but a coordi-nated effort among two professionalsor groups of professionals8

Best practices for safe and effectivepatient handoffs include implementingthe following methods4bull Use a standardized process for eachtype of handoff situation (definedby the organization and understoodby the staff members who partici-pate in the hand off )

bull Include specific minimum contentincluding up-to-date informationregarding the patientrsquos care treat-ment services condition and anyrecent or anticipated changes

bull Allow an opportunity for thereceiver of the handoff informationto review relevant patient historicaldata which may include previouscare treatment and services

bull Use a verification process such as aldquoread-backrdquo or ldquorepeat-backrdquo forcritical information as determinedby the organization

bull Allocate specific time for handoffsbull Allow for the opportunity to askand respond to questions

bull Limit interruptions during handoffs

Key information that should beshared during the handoff processincludes contact information for theprimary team complete patient identi-fication data an active problem listpertinent past medical information his-tory current condition active andupdated medication and allergy listscode status anticipated changes in thenext care interval with a recommendedcourse of action and psychosocial con-cerns that may influence therapeuticchoices4 Furthermore some expertshave advocated that the handoff includea patientrsquos cognitive acuity status infor-mation on venous access discussions oflevel of care and listing long-term plansin case families have questions perti-nent laboratory data pending testsconsults and procedures4 For a briefdiscussion of some of the barriers to

effective handoff communication seethe sidebar above

Developing the SBAR Tool SBAR provides a systematic approachto improving communication amonghealth care team members The tech-nique is adaptable to different types ofhandoff situations such as nurse-to-nurse nurse-to-physician ornurse-to-transporter communicationSBAR consists of the following fourcomponents81 Situation What is going on withthe patient Identify yourself andthe patient State the problem

2 BackgroundWhat is the back-ground on this patient Review the

chart before speaking up if the situa-tion allows the time Anticipatequestions the other care providermight have

3 Assessment Provide your observa-tions and evaluations of the patientrsquoscurrent state

4 Recommendation Make aninformed suggestion based on soundinformation for the continued careof the patientWhile at CHRISTUS St Vincent

Regional Medical Center I perceived aneed for a new handoff communica-tion tool As one of only six surgeonsin the group caring for everything fromappendicitis to multisystem trauma



Sidebar Barriers to Effective Handoffs

The following are five major barriers to safe and effective handoff

communications

1 The physical setting The physical environment in which the handoff occurs can

influence its effectiveness for better or worse Patient confidentiality requires

that the handoff take place in private The setting should be reasonably quiet

away from background noise created by other staff televisions and patients

The setting should have appropriate lighting ample writing space and should

be designed to limit interruptions (closed door etc)

2 The social setting The social setting should be selected so as to allow both

parties to feel comfortable discussing treatment options Research has

shown that communication failures sometimes arise as a result of status

differences as well as concerns with hierarchy and interpersonal power and

conflict

3 Language barriers Research indicates that racial and ethnic minorities and

persons with limited English face barriers to care even when translators are

available While physicians often speak the same ldquomedical languagerdquo much

can be lost in translation during communication among physicians of

different cultural backgrounds or those who originate from different regions

of the same country Consequently colloquialisms and abbreviations should

be avoided

4 Time and convenience issues There is no denying that handoffs can be

time-consuming and inconvenient Research has indicated that the amount

of time health care providers feel they have to perform the handoff can

greatly influence its content

5 Medium of communication Handoff communication should always be direct

in-person communication and written information should be transferred at

the same time as verbal information Communication by telephone e-mail

paper and other computerized systems reduces the number of information

channels (such as tone body language and so forth) involved in the

exchange and therefore creates more room for assumptions and error

Source Solet D etal Lost in translation Challenges and opportunities in physician-

to-physician communication during patient handoffs Academic Medicine

801094ndash1099 Dec 2005


The experience of moving a hospital toa new facility can be harrowing forstaff patients and their families Thisis the first in a series of two articles discussing the ways in which two hospi-tals took this challenge on whilemaintaining quality of care andpatient safety When the Johns Hopkins Childrenrsquos

Center in Baltimore Maryland wasbuilt in 1962 only 10 of parents andfamily members ldquolived inrdquo the facilityduring their childrsquos hospital stay that isremained with the patient during theentire stay Now 85 of parents andfamily members live at Johns HopkinsChildrenrsquos Center says Ted Chamberspediatrics administrator Unfortunatelythe rooms in the current building donot accommodate all the family mem-

bersrsquo needs To improve family-centeredcare and enhance patient safetyHopkins Childrenrsquos plans to open thenew Charlotte R Bloomberg ChildrenrsquosCenter in 2012 ldquoThe new ChildrenrsquosCenter will be state of the art and willallow us to provide safer carerdquo saysMichael Iati senior director of architec-ture and planning Johns Hopkins ldquoItrsquosamazing to see the quality of health carealready delivered in our outdated build-ings so Irsquom excited to see what wersquoll doin a brand new buildingrdquoNorthwest Community Hospital

(NCH) in Arlington Heights Illinoisrecently moved into a new hospitaltower Wherein the new space rein-forced the organizationrsquos family-centeredvalues the new tower provides familymembers with their own space within

each private patient room as well asadditional family support areas andconference rooms Patient rooms in thenew tower make it easy for familymembers to participate in patient carewithout getting in the way of the rou-tine care provided by nurses andphysicians says Pat Stack vice presi-dent of transition planning at NCH Inaddition the new tower at NCH isequipped with a state-of-the-art specialcare nursery that can accommodatemore patients and provide privacy forpatients and families ldquoOne motheractually started crying when she touredthe special care nursery in the newtowerrdquo says Stack ldquoBecause she hadher first baby in the old special carenursery where it was open and pro-vided limited privacy during a time ofcrisis she was so happy to see the newprivate environmentrdquo

Planning the Layout of theNew FacilityPrior to building the replacement hos-pital Hopkins Childrenrsquos had thechance to experiment with a set of testpatient rooms when they renovated afloor of the current hospital ldquoWe splitthe floor in half and tested two differ-ent designsrdquo said Chambers ldquoOnething we learned was that parents needsome time away from their sick childbut they donrsquot want to be too far awayfrom the child for too long of a timeAs a result parents used family supportareas for a limited time So we foundthat little alcoves outside the patientroom were better suited for parents toleave the room get coffee and restwhile still in sight of their childrdquo Parents and family members also

have the opportunity to test an idea on the current hospital that can be

Moving Your Hospital to a New Facility Part 1

The Planning Phase

Extensive and careful planning is necessary before hospitals can begin to move into anew facility


implemented in the new ChildrenrsquosCenter ldquoOur Family Advisory Councildecided to test sibling support areasrdquosays Chambers ldquoIf these areas test wellwe hope to provide this service in thenew buildingrdquoAlthough new facilities can offer

patients and family members privacyand comfort with private rooms andfull bathrooms within each patientroom those amenities can come at anexpense ldquoWith private and largerrooms it means much longer corridorsand patients that are spread furtherapartrdquo says Hopkinsrsquo Iati ldquoIn the newbuilding we can provide patients andfamilies with amenities and make therooms largerrdquo adds Chambers ldquoButthe end product is a larger facilityContrasted with what we have nowwhich is intimate and nurses can see tothe end of the hall and easily signalcoworkers when necessary the newhospital is about a football field and ahalf in length and the pediatric inten-sive care unit for example is in an ldquoLrdquoshape so you canrsquot see from one end tothe nextrdquo Similarly the floors on the old tower

at NCH are 11000 square feet whilethe floors on the new tower are 33000square feet ldquoAll this extra space meansless visualization of patientsrdquo saysStack ldquoOpen environments donrsquot pro-vide privacy for patients but they aregreat for team work because caregiverscan see whatrsquos going on with all thepatients Wersquore dependent on sightlines as a component of patient safetybut with private rooms and long hall-ways staff canrsquot easily see whatrsquos goingon with the patients or their cowork-ersrdquoTo combat the expansive hallways

lack of patient sight lines anddecreased visual communicationamong staff on the new larger unitsorganizations can help keep nursesclose to the bedside and provide alter-native routes of communicationbetween patients and caregivers

Bring Nurses andSupplies to the BedsideldquoWith the layout of the new hospitaltower we knew that we would have tochange processes to keep nurses as closeto the bedside as possiblerdquo say NCHrsquosStack ldquoWe instituted a new supply dis-tribution system that allows frequentlyused supplies equipment and linens tobe kept close to the bedside and remainwell stocked so that nurses wouldnrsquotneed to run back and forth to supplyrooms In addition we provided spacefor computers in the new rooms so thatnurses can document at the bedsiderdquoHopkins Childrenrsquos also believes

stocking supplies close to the bedsidewill enable the nurse to have more timeat the bedside ldquoThe goal is to have85 of what staff needs on a routinebasis at or near the patientrsquos room(within a step or two) and the remain-ing 15 donrsquot always need nearbysupply roomsrdquo says Iati ldquoCaregivers on

pediatric units donrsquot have to travelmore than 5 patient rooms to get tothe central supply roomsrdquo

ProvideAlternative Methods ofCommunication With long hall-ways in the new hospitals staff andpatients are spread out Nurses arenrsquotalways near patient rooms to easilyanticipate patientsrsquo needs and cowork-ers arenrsquot within eyesight to call forassistance ldquoSafety is in communica-tionrdquo says Hopkinsrsquo Chambers ldquoandbecause we wonrsquot have as much visualcommunication in the new buildingwe need to provide methods for audi-tory communication such as throughthe improved nurse call systemrdquo NCH also implemented an updated

nurse call system ldquoThe nurse call sys-tem is designed to integrate with thewireless phones that nurses carryrdquo saysStack ldquoIf a patient needs the nurse he

STRATEGY

STRATEGY

Patient rooms in Northwest Community Hospitalrsquos new hospital tower were designed tokeep nurses as close to the bedside as possible


or she will hit the call button and a sig-nal will go directly to the phone of thenurse assigned to that patient ratherthan going to the secretary who needsto find the nurse This helps the nursebe more available to the patientrdquo

Educating and Preparing StaffPrior to transitioning to a new spaceStack suggests providing staff with thefollowing education1bull Communicating new clinicalcompetencies associated with thenew environment

bull Life safety training (locating fireexits fire alarms fireextinguishers and oxygen shut-offs orienting to new securitysystem use of hand-held radios)

bull Training on new equipment (forexample new transfer equipmentin patient rooms nurse callsystem and new telephones)

bull Workflow exercises (practicinghow to provide care on the newunits through scavenger huntsand conducting mock moves toensure staff know what route totake when transferring patientson moving day including whichelevators to use)

ProvideEducation in a TimelyManner Organizations need to pro-vide education related to the newbuilding within an appropriate amountof time prior to the move to facilitatestaff retention of the information butnot too close to the move so as to over-whelm staff When possible newequipment should be implemented inthe current building prior to the moveso that the amount of necessary educa-tion can be reduced ldquoWe donrsquot want tomove into the new building with staffcoping with new processes and systemsin addition to adjusting to the new facil-ityrdquo says Hopkinsrsquo Chambers ldquoWe wantstaff to be familiar with any new equip-ment or processes before the move So

wersquove spent a lot of time with pilot proj-ects and training to provide a saferenvironment for the new buildingrdquoThroughout their transition experi-

ence NCH learned that it should haveprovided more time to educate staff onthe new telephones and nurse call sys-tems ldquoUnfortunately we couldnrsquot orderour current phones for the new buildingso we had to purchase new phonesrdquo saysStack ldquoWe scheduled training for thenew phones but a lot of people didnrsquotcome to training because itrsquos a phoneand it seems intuitive However thesenew phones were more complex than wethought and staff struggled Wersquove had toschedule more training on the phonesafter the move Additionally the com-plexity of the nurse call system was asurprise And we had to rework someprogramming down to the last minutebefore the moverdquo

Give Staff Timeto Orient to the NewBuilding ldquoAfter we take possessionof the building from the contractorabout three to four months before themove-in date wersquoll take every opportu-nity to orient staff to the newbuildingrdquo says Iati ldquoThey need toknow where bathrooms are how towork new medical equipment knowwhat the phone numbers are andunderstand how to use the phones Itrsquosa huge deal to change everything some-one knows about the environment inwhich they care for patients Thephone isnrsquot where it used to be and youturn left where you used to turn rightto get to the supply room Itrsquos a lot ofadjustment emotionallyrdquo

The second article in this two-partseries which will publish in theNovember 2010 issue of Perspectives onPatient Safety provides strategies for asafe and efficient moving day

Reference1 Ecoff L Thomason T Moving into a newhospital Strategies for success J Nurse Adm19499ndash503 Dec 2009

PS

STRATEGY

STRATEGY

Access The Joint

Commission Perspectives on

Patient Safety Online

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lsquoMy Ingentarsquordquo Click ldquoActivating

Personal Subscriptionsrdquo and

then click the ldquoAddrdquo tab

5 Find the publication to which

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ldquoJrdquo to find ldquoJoint Commission

Resourcesrdquo and then find the

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Perspectives on Patient Safety

6 Check the small box to the left

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7 In the larger box to the right of

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ber is your last name and your

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After you have registered you can

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contentjcahojcpps

Joint Commissionrsquos NPSG150201requires home care organizationsto identify the specific risks associ-

ated with home oxygen therapy suchas home fires In a 2008 National FireProtection Association report homeoxygen therapy was found to be a con-tributing factor in an average of 1190burns per year as seen in US emer-gency rooms Moreover from2002ndash2005 fire departmentsresponded to an average of 182 homefires per year in which oxygen adminis-tration equipment was involved inignition Forty-six people per year diedin these fires1

Common risk factors that healthcare organizations should watch forwhen assessing home fire risk includebull An identified history of smokingwhile oxygen is running

bull Flammable clothingbull Lack of smoke detectors or thepresence of non-functional smokedetectors

bull Patient suffers from cognitiveimpairment

bull Patient living alone

Risk AssessmentldquoA home care organizationrsquos first step in oxygen safety is to perform a riskassessmentrdquo says Diane Flynn RNMBA Joint Commission home caresurveyor Before home care organiza-tions that supply oxygen can provideproper education in the risks and useof the equipment the organizationmust perform a comprehensive assess-ment and identify the specific risks ineach patientrsquos home A home monitor-ing program and follow-up should beput into place as well particularly incases in which a patient is determinedto be at high riskThe final assessment should be of

the patientrsquos comprehension of identi-fied risks and suggested interventionsCompliance will need to be reviewedperiodically especially with patientsidentified as suffering from cognitiveimpairment2

Smoking and Home OxygenSmoking is by far the leading cause ofburns reported fires deaths andinjuries involving home medical oxy-gen Smoking materials are the leadingheat source comprising 73 of med-ical oxygenndashrelated burns seen athospital emergency rooms1

If a risk assessment has demon-strated that a patient smokes or thereare smokers in the patientrsquos home thefamily must be educated in safetyguidelines For example smoking may

occur if the oxygen unit is shut off andthe patient or family member agrees toonly smoke outside of the home The National Fire Protection

Association recommends that smokingnever occur in a home where oxygen isused and suggests that patients post lsquonosmokingrsquo signs in and outside of thehome to remind residents and guestsnot to smokeThe home care organization may

want to consult its ethics committee ororganization leadership regarding thetermination of services to a patientwho has had a history of smokingwhile oxygen is running or is noncom-pliant with precautions

Flammable Clothing OpenFlames and Other HomeHeat SourcesWhile the danger of a lit cigarette isobvious some other fire risks might beless apparent and must be included inpatient education While oxygen itselfis not flammable it is necessary for fireto burn and its presence in high con-centrations will make a fire burn fasterand hotterndashturning a tiny spark into aconflagration Materials such as wool and nylon

can produce static electricity whencombined with friction such as when apatient walks in socks on a nylon car-pet or removes a wool sweater In anoxygen rich environment a static sparkcan cause a burn or a fire Candles and gas stoves should be

avoided when using medical oxygenPatients should stay at least six feet awayfrom any open flame or other heatsource when using their oxygen systemIf a patient must cook while using oxy-gen tubing should be positioned behindthe patient or tucked into his or her


Home Oxygen Therapy Complying with NPSG150201

Home oxygen therapy requires carefulplanning and monitoring to prevent fires

shirt to avoid coming into contact withthe gas flame or electric burner4

Patients Suffering fromCognitive Impairment As part of the initial safety assessmenthome care organizations should iden-tify the patientrsquos level of comprehensionof and ability to comply with identifiedrisks and suggested interventionsPatients identified as suffering fromcognitive impairment will need addedassistance in setting up a home envi-ronment conducive to safe medicaloxygen use Home care organizationswill need to ensure a home health aideor family member adequately under-stands the safety risks and precautionshe or she may need to take on behalf ofthe patientSome oxygen use precautions offered

by Cleveland Clinic Health Systemcould be implemented by a patientrsquosfamily member or caregiver These pre-cautions include the following4bull Be sure that all electricalequipment in the area near theoxygen is properly grounded

bull Secure floor mats and throw rugsso that patient will not trip or fallwhen using an oxygen system

bull Keep the oxygen system properlysecured in a well-ventilated areaand in a place where it wonrsquot getknocked over

bull Keep the oxygen system clean anddust-free

Patients Living AloneSentinel Event Alert 17The Joint Commission reviewed 11sentinel events in which home healthcare patients using supplemental oxy-gen were injured or killed by fire3

Living alone was among the commonrisk factors When a fire or burnoccurs these patients are most at riskof injury or even death

Home care organizations might con-sider the following3bull Place a phone near the bed orchair of people who may havedifficulty escaping a fire

bull Make sure that the home hasworking smoke alarms Test themat least monthly

bull Have a fire extinguisher easilyaccessible in the home and makesure the patient knows how to useit

bull Have a home fire escape planwith two ways out of every roomand practice the plan at leasttwice a year

bull Notify patientrsquos electric companyif he or she is using an oxygenconcentrator system so they canmake that house a priority duringa power outage

While home fires are a significant riskfor the home oxygen therapy patientother risk factors can be mitigated aspart of an educational program includ-ing the following examples bull Patients may not be getting theamount of oxygen his or herdoctor has prescribedOrganizations can test to ensurethat the oxygen is delivered atproper levels

bull Improperly stored tanks whichcan fall and rupture could act asa ldquotorpedordquo smashing throughwalls and could injure anythingin their path

bull Loose cords or extra tubing canbe trip and fall hazards

bull Patients living far from theiroxygen supplier should havebackup tanks available in casethey run out and severe weatherconditions make delivery difficult

References1 Ahrens M National Fire Protection

Association Fires and Burns Involving HomeMedical Oxygen Aug 2008

httpwwwnfpaorgassetsfilespdfosoxygenpdf (accessed August 15 2010)

2 The Joint Commission ComprehensiveAccreditation Manual for Home CareOakbrook Terrace IL The Joint CommissionJul 2010

3 The Joint Commission Lessons learned Firesin the home care setting Sentinel Event AlertMar 2001 httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_17htm(accessed Sept 7 2010)

4 The Cleveland Clinic Home Oxygen Therapyhttpwwwcchsnethealthhealth-infodocs24002412aspindex=8707 (accessed Sep 72010)

PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

Readers no longer have to wait a

whole month for new information

from Perspectives on Patient Safety

The editor is regularly posting to a

blog on the Joint Commission

Resources Web site to provide

supplemental information to the

articles in the newsletter and other

news See httpwwwjcrinccom

Blogs-All-By-Category

Perspectives-on-Patient-Safety-Blog

Whatrsquos more this blog gives you the

reader an opportunity to give

feedback about the newsletter and

voice your opinions on the issues

discussed in the blog and in print

Call for Papers

Are you or your organization

working on a project or policy that

will improve patient safety

Why not share your ideas and

results with your colleagues

nationwide

If you have a paper you would like

to submit for potential publication

in Perspectives on Patient Safety

please send us an e-mail at

patientsafetyjcrinccom

covering for the weekend was fraughtwith a potential for missed or partialinformation I was uncomfortable withthe hand-scrawled notes on a variety ofpaper sorts some with patient ldquostick-iesrdquo listing their name age andmedical record number I decided toincorporate the SBAR technique intoan active PDF form I created thatwould allow text entry into the fields ofthe document and that could be com-pleted by anyone with access to acomputer Since it was a PDF a freesoftware program Adobe Readerreg wasall that was needed to complete theform and was platform neutral avail-able for PC or Mac operating systemsMy partners loved the handoffs I pro-vided to them during the weekendhandoff My experience led me to partner

with the chief operations officer todevelop an on-line tool for the entireorganization replicating the PDF doc-ument but linked to the hospitalrsquospatient demographics and physiciandatabase The on-line system was devel-oped but for a variety of reasons neverldquogot off the groundrdquo SBAR has a positive track record in

health care For example St JosephMedical Center implemented SBAR in2005 Shortly thereafter their rate ofadverse events fell to 3996 per 1000patient days in fiscal year 2005 from899 per 1000 patient days in fiscalyear 2004mdasha 4994 reductionAdverse drug events fell from 2997 per1000 patient days to 1764 per 1000patient daysmdasha 1233 reduction9

One would hope that data like thiswould be very compelling to an organi-zation to implement a methodologylike SBARJust imagine the safety boost an

organization would get if SBAR wereused from the front door to dischargeThese kinds of results are only

possible when organizationwide stan-

dardization is implemented St Josephmade SBAR implementation a keyproject in its strategic plan for 2005and with the support of leadership cre-ated an interdisciplinary team tofacilitate the implementation Theteam included the chief nurse officerthe patient safety officer and the med-ical director as well as representativesfrom several hospital departments

The second part of this article willaddress strategies for standardizing hand-off processes throughout your entireorganization

Michael S Woods MD MMM isa leadership expert surgeon and authorof several books including In a BlinkHealing Words Civil Leadership TheDEPO Principle and was editor ofCultural Sensitivity A Pocket Guidefor Providers Dr Woods is a recognizedauthority on provider-patient communi-cation and relationships patientsatisfaction and strategies to reduce med-ical malpractice Dr Woods is thefounder of Civility Mutualreg EducationalServices an organization dedicated tohelping physicians and health care staffwith relationship-based care and improv-ing patient-provider communication aswell as the Vice President of MedicalAffairs for the Johnson Health Networkin Stafford Springs CT

References1 Zimmerman PG Cutting-edge discussions ofmanagement policy and program issues inemergency care J Emerg Nurse 32267ndash268Jun 2006

2 The Joint Commission HandoffCommunications Toolkit for Implementing theNational Patient Safety Goal Oakbrook TerraceIL Joint Commission Resources 2008

3 Hall M Dugan E Zheng B Mishra ATrust in Physicians and Medical InstitutionsWhat is it can it be measured and does itmatter The Milbank Quarterly Vol 79 No4 2001

4 Anderson J Shroff D Curtis A et al TheVeterans Affairs shift change physician-to-physician handoff project Joint Comm J QualPat Saf 3662ndash71 Feb 2010

5 The Joint Commission Improving AmericanrsquosHospitals The Joint Commissionrsquos Annual Reporton Quality and Safety httpwwwjointcommissionorgNRrdonlyres658A9BB9-3485-4ACB-91BF-FCDCA73E4F3002007_Annual_Reportpdf(accessed Sept 1 2010)

6 Kitch B Cooper J Zapol W et alHandoffs causing patient harm A survey ofmedical and surgical house staff Jt Comm JQual Pat Saf 34563ndash570 Oct 2008

7 Patterson E Wears R Patient handoffsStandardized and reliable measurement toolsremain elusive Jt Comm J Qual Pat Saf3652ndash61 Feb 2010

8 Amato-Vealey E Barba M Vealey R Hand-off communication A requisite forperioperative patient safety AORN J 88 763-770 Nov 2008

9 Shaw T Communication Making transitionssafer with standardized handoffs Paper pre-sented at the Society for Pediatric Anesthesia23rd Annual Meeting New Orleans Oct 162009

PS




An interdiscipinary team is essential to the development of a successful SBAR program

Volume 10 Issue 10 October 2010

Send address corrections toensp

The Joint Commission Perspectives on Patient Safety

Superior Fulfillment

131 W First St

Duluth MN 55802-2065

800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL

For more information please visit httpwwwFluVaccinationChallengecom or call our

toll-free Customer Service Center at 877223-6866 Our Customer Service Center is

open from 8 AM to 8 PM EST Monday through Friday

During the 2009ndash2010 flu season organizations participating in the Flu Vaccination Challenge yielded an average immunization rate of 76mdasha 13 increase over the rate reported in 2008ndash2009 and 27 above the national health care worker vaccination average

For the 2010ndash2011 flu season the third annual Flu Vaccination Challenge is continuing to raise the bar among health care workers toincrease their flu vaccination rates This year your health care organization is encouraged to achieve one of the three tiers below

Show your commitment to the health of staff and patients Meet The Challenge

For additional information on how health care workers can help improve vaccination rates please visit httpwwwFluVaccinationChallengecom

Funding and other editorial support for The Flu Vaccination Challenge has been provided by GlaxoSmithKline

wwwjcrinccom

Patient SafetyPulseYour Patient Safety News

Joint Commission Announces Changes to

NPSG010301

2 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY October 2010

Top 5 in the News

Senior Editor Jim ParkerProject Manager Bridget ChambersManager Publications Helen M Fry MAExecutive Director of Publications

Catherine Chopp Hinckley PhDContributors Meghan Pillow RN

Rachel Brickman Levin

Subscription Information The Joint Commission Perspectives on Patient SafetyTM (ISSN 1534-5181) is published monthly(12 issues per year) by

Joint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace IL 60181

Send address corrections to The Joint Commission Superior Fulfillment131 West First StreetDuluth MN 55802-2065

Annual subscription rates for 2010Domestic $319 for print and online $299 foronline only international $410 for print and on line$299 for online only Back is sues are $25 each(postage paid) To begin your subscription call800746-6578 fax orders to 218723-9437 or mailorders to Joint Commission Resources 16442 Col-lections Center Drive Chicago IL 60693

Editorial policy Reference to a name an organization a product or a service in The Joint Commission Perspectives on Patient SafetyTM

should not be construed as an en dorsement byJoint Com mission Resources nor is failure toinclude a name an organization a product or aservice to be construed as disapproval

copy 2010 by The Joint Commission No part of thispublication may be reproduced or transmitted inany form or by any means without written permis-sion

Joint Commission Resources Inc (JCR) an affiliate of The Joint Commission has been designated by The Joint Commission to publishpublications and multi media products JCR reproduces and distributes these materials underlicense from The Joint Commission

Visit us on the Web at httpwwwjcrinccom

1Disclose Errors Health care organi-

zations should disclose medical

mistakes that affect multiple patients

even if patients were not harmed by

the event according to the Agency for

Healthcare Research and Quality

2Vaccination Up Among Teens

Increases of as much as 15 percent

were made in nationwide coverage for

vaccines among 13- to 17-year-olds

according to 2009 National

Immunization Survey-Teen estimates

recently released by the Centers for

Disease Control and Prevention

3JCR Vaccine Challenge Begins

Joint Commission Resources has

launched its 2010ndash2011 Flu

Vaccination Challenge to promote

health care worker vaccination

During the 2009-2010 flu season the

Flu Vaccination Challenge yielded an

average immunization rate of 76mdasha

13 increase over the rate reported in

2008ndash2009 and 27 above the

national average Visit wwwjcrinccom

fluchallenge for more information

4Patients Skip Care Due to Cost

According to a Deloitte Center for

Health Solutions survey 79 of 4008

patients surveyed visited a physician

or health professional in the previous

year down from 85 in 2009 More

than 40 of all respondents said they

delayed care because of cost

5New Patient-Centered Care

Resource The Joint Commission

has released a new monograph on

patient-centered care and communica-

tion The monograph is available for

free download at The Joint

Commission Web site at

httpwwwjointcommissionorg

PatientSafetyHLC

The Joint Commission has approved revisions to NPSG010301 EP 1 Theserevisions were approved subsequent to the publication of the September 2010special National Patient Safety Goals issue of Perspectives on Patient SafetyNPSG010301 requires accredited organizations to ldquoEliminate transfusion

errors related to patient misidentificationrdquo The requirement applies to ambu-latory care organizations hospitals critical access hospitals and office-basedsurgery practices The revised element of performance reads as follows 1 Before initiating a blood or blood component transfusion

bull Match the blood or blood component to the orderbull Match the patient to the blood or blood componentbull Use a two-person verification process or automated identificationtechnology such as bar coding

(See also NPSG010101 EPs 1 and 2)Before these revisions the language regarding ldquoautomated identification

technologyrdquo in the third bullet point was contained in a note This revision iseffective immediately Research indicates that most transfusionndashrelated errors occur because a

blood sample for laboratory testing is mislabeled or a patient isnrsquot properlyidentified at the bedside before a blood transfusion begins1

References1 Linden J et al Transfusion errors in New York State An Analysis of 10 yearsrsquo

experience Transfusion 401207ndash1213 2000

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Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























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131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL







































































communications











conflict







be avoided













801094ndash1099 Dec 2005










The Planning Phase












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STRATEGY

STRATEGY

Access The Joint



1 Go to








ldquoRegisterrdquo





















Smith12345)



number box





one hour




contentjcahojcpps











































PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL


















The Planning Phase












STRATEGY

STRATEGY














PS

STRATEGY

STRATEGY

Access The Joint



1 Go to








ldquoRegisterrdquo





















Smith12345)



number box





one hour




contentjcahojcpps











































PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL



















STRATEGY

STRATEGY














PS

STRATEGY

STRATEGY

Access The Joint



1 Go to








ldquoRegisterrdquo





















Smith12345)



number box





one hour




contentjcahojcpps











































PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL





















PS

STRATEGY

STRATEGY

Access The Joint



1 Go to








ldquoRegisterrdquo





















Smith12345)



number box





one hour




contentjcahojcpps











































PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL



















































PS


Home Oxygen Therapy


The Perspectives on

Patient Safety Blog

















Call for Papers






nationwide
























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL



























PS









131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL













131 W First St


800746-6578

Non-Profit

Organization

US Postage

PAID

Permit No 174

Palatine IL









joint commission- sbar pt1- oct10

Documents