Professor Peter Gillen, Associate Professor of Surgery at the Royal College of Surgeons in Ireland, looks at the risks of poor communication during handover – and assesses one potential safety net for clinicians
Clinical handover is essentially about communication between team members: handovers require clinicians to talk and perhaps write to each other. Ineffective communication between team members is a well-recognised contributor to patient harm.
Let’s consider the following interaction between a laboratory staff member and a member of a medical team:
Lab: “This is the lab. I’m ringing about Mrs X’s blood culture.”
Staff member: “Oh right – go ahead.”
Lab: “You were right! The blood culture is positive. It’s positive. Positive for E.coli. So, positive blood culture – ok?”
Staff member: “Right thanks. Got that!”
A short while later this staff member is asked if the lab had rung through with results on the blood culture yet. Their reply: “Oh yes they did. It’s a gram-positive blood culture. It was positive all right!”
The patient in question – Mrs X – then receives inadequate antibacterial cover for her sepsis, as the staff believe they only need provide gram-positive cover, whereas E.Coli requires gram-negative cover. By the time the error is realised – when the printed report becomes available – Mrs X’s condition has deteriorated and, despite all further interventions, she dies.
A widespread problem
Too far-fetched? I’m afraid this is a true story and accounts for one of the many adverse incidents – in this case a tragic mortality – that have been highlighted by a large-scale project carried out by the European Commission in 2015. This study found that communication relating to handovers is responsible for between 25-40% of adverse events.
The World Health Organisation has listed improved handover communication in its top five patient safety solutions. Poor handovers cause a range of problems from reducing efficiency, delays in discharge or time to operation, unnecessary delays in diagnosis, treatment and care, missed or delayed communication of test results (as in the case of Mrs X), and incorrect treatment or medication errors.
With the incidence rate of adverse events as high as this, the need for clear and efficient communication in the healthcare setting is crucial. This relies on all healthcare staff having not only mutual understanding and respect but also being able to demonstrate it in the method and content of their communication with patients, their families and with each other.
ISBARRR (Introduction, Situation, Background, Assessment, Recommendation, Read-back and Risk)
The acronym ISBARRR, or ISBAR3 as it is known, is a refinement of the original SBAR technique for transfer of information developed by Kaiser Permanente in the United States and adopted by the nuclear submarine industry – one could hardly think of an environment where errors could be more costly.
Use of ISBAR3 is the most effective way to transfer information safely in healthcare when performed properly:
Introduction: identify yourself and the patient
Situation: describe the current situation
Background: relevant background information about the patient
Assessment: your evaluation of the patient and possible diagnosis
Recommendation: your recommended course of action
Read-back: asking the receiver to repeat the information back to you
Risk: what risks, if any, apply to this patient for the organisation.
Communication exchange between two parties involves the transfer of information from the sender to the receiver. This, however, is only half the battle. Before the sender can be sure that the receiver has received the message in the way it was intended, they need the receiver to confirm that this message has been received and understood as intended.
This requires some form of ‘feedback’ – now incorporated as “Read-back”, where the sender listens to the receiver read back what they have just been told. This safety net allows both the sender and receiver to ask and answer any queries that might arise. Hearing the information repeated back also allows the sender to add in other details that may have been initially forgotten or overlooked.
The idea of Read-back may be relatively new in medicine and, as such, may suffer from a degree of push-back from staff uncomfortable with the idea or too embarrassed to ask a senior colleague: “Please could you tell me what I just told you?”
Changing culture
Expecting culture change to occur simply by introducing new ways of communicating may be naïve. The successful introduction of change requires good leadership and buy-in from staff – which will only happen if staff perceive the change is relevant and of help to them in their work practice. The rest is practice and positive encouragement allied with helpful feedback. The expected response, “oh I don’t have time to do that”, is best met with the response that ISBAR3 need not take extra time at all and the benefits are there for both patients and staff.
ISBAR3 is equally suitable for emergency situations in medicine. It can and is being used in emergency departments currently, with success. It should be remembered that communication and transfer of information in particular, may deteriorate in emergency situations. When emotions are high it’s likely that communication will face an uphill struggle. We owe a great deal here to the aviation industry, who introduced the concept of crisis resource management (CRM). This philosophy of stressing the importance of non-technical skills required for effective teamwork in a crisis situation marries well with ISBAR3, supporting the communication pillar of CRM.
Communicating in crises still requires the essential component of being secure in the knowledge that the message sent is indeed the message received as intended – perhaps even more so where immediate decisions may have to be taken on the basis of information received. Adrenaline can help and hinder the same individual at the same time.
Stress responses in emergencies vary greatly between individuals and simulation training is one way of mitigating the impact of those adrenaline rushes. Reliance on memory of facts, details of injury and vital signs is fraught with danger and should be replaced where possible by use of a structured format of information giving. ISBAR3 is such a structured format. It can and will save lives.
Try to imagine the difference had that laboratory worker calling about Mrs X finished by saying: “Now can you read that back to me please?”
- For more on safe handovers, listen to Professor Gillen speak with Dr Sarah Coope, Senior Medical Educator at Medical Protection, in the podcast “Handovers part 2: How to structure safe and effective handovers”, available here