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August 19, 2006
The Wall Street Journal* reports that the Joint Commission on Accreditation of Health Care Organizations (JCAHO) is requiring hospitals to establish standards for hand-off communications, as evidence suggests communication breakdowns during patient hand-offs are the single largest source of medical error. Hospitals have ad-hoc hand-off procedures, the article reports, but they are not standardized and nurses are often uncomfortable giving their own patient assessments to incoming physicians.
St. Joseph Medical Center uses the SBAR checklist successfully to improve physician and nurse communications, which stands for Situation, Background, Assessment and Recommendation. This protocol was adapted from a nuclear submarine program used to quickly brief staff during a change in command.
At St. Joseph Medical Center, cases of harm to patients fell by more than half in the year after the SBAR program was implemented.
Read the entire article at the Post-Gazette.com
*Hospitals Combat Errors at the 'Hand-Off': New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift, June 28, 2006.
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