handout toolkit 07 - Washington Patient Safety …

1 Handoff CommunicationsCourtesy of Banner Health. Used with CommunicationsCourtsey of Parkwest Medical Center. Used with permission. SPatient ID LabelHereSurgeon: Procedure:NPO Status: Ht/Wt:Site Marked:Procedure:Anesthesia Type: General Epidural Spinal Local MAC Other:History: (circle) Other:Neuro Seizures - DM Cardiac Dz Dysrhythmia HTN Resp Dz Asthma Renal Dz Liver Dz Malignant Hyperthermia Allergies: Isolation (circle) MRSA VRE TB - Other: Cultural/Interpreter: / Personal Belongings: _____ Given to:_____ BFamily Contact Info: Location: Waiting Room Unavailable Contact #:ASUoPSAoORo PACU/ASU/CCU T/HR/BP/RR/SaO2:Skin: Neuro: Pulmonary.

2 Cardio/Rhythm/PV: GastroIntestinal: GU/Cath/Drains: Circle: Foley CBI - JPx___- Hmvac Other: Dressings: Musculoskeletal: Pain: Epidural/Block: IV Site & IVF LTC: Site: LTC: Site: LTC: Site: LTC: Lines (CVL,A-Line): Intake/Output & EBL: I= O= I= O= I= O= EBL: Meds/Reversal Given: Infusions: Blood Given/Needed: Given: Needs: Given: Needs: AAbn Labs & Last BS: BS= BS= BS= BetaBlocker Protocol: Yes No N/A Yes No N/A Yes No N/A DVT Protocol: Yes No N/A Yes No N/A Yes No N/A Other: Special Equipment: Acute Orders: Unexpected Events: Post Op Destination.

3 ASU CCU Floor ASU CCU Floor ASU#_____ CCU #_____ Floor Room #_____ RMeds (Antibx) needed Handoff CommunicationsCourtesy of Department of Defense Patient Safety Program. Used with permission. IIntroductionIntroduce yourself and your role/job (includepatient)PPatientName, identifiers, age, sex, location AAssessmentPresenting chief complaint, vital signs and symptoms and diagnosis SSituationCurrent status, medications, circumstances, including code status, level of (un)certainty, recent changes, response to treatment SSAFETYC oncernsCritical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation, etc.)

4 THEBB ackgroundCo-morbidities, previous episodes, past/home medications, family history AActionsWhat actions were taken or are required AND provide brief rationale TTimingLevel of urgency and explicit timing, prioritization of actions OOwnershipWho is responsible(nurse/doctor/team) including Patient /family responsibilities NNextWhat will happen next? Anticipated changes?What is the PLAN? Contingency plans? Handoffs and Healthcare Transitionswith opportunities to ask QUESTIONS, CLARIFY and CONFIRM IIIPPPAAASSSSSSTHEBTTHHEEBBAAATOTTOONNN Handoff Communications Kaiser San Francisco Perioperative Services RN TO RN HANDOFF TOOL ( - PACU / CVICU) DATE _____** SITUATION ( Patient history).

5 Patient S AGE & _____ PRE-OPERATIVE DIAGNOSIS _____ PERTINENT MEDICAL HISTORY _____ OPERATIVE PROCEDURE _____ (include side and site)ALLERGIES YES _____ NKDA SENSORY IMPAIRMENT YES _____ NO FAMILY PRESENT ASU WAITING ROOM 5TH FLOOR CVOR WAITING ROOM RELIGIOUS/CULTURAL ISSUES YES _____ NO ISOLATION PRECAUTIONS YES _____ NO INTERPRETER REQUIRED YES _____ NO VALUABLES / BELONGINGS _____ (disposition) INTRAOPERATIVE BACKGROUND.

6 MEDS GIVEN INTRAOPERATIVELY _____ BLOOD GIVEN YES NO TRANSFUSED _____ RBCs, _____ PLATELETS _____ FFPS UNITS AVAILABLE _____ ASSESSMENT OF SKIN INTEGRITY _____ (include pressure sites, positioning related areas and incision site) MUSCULOSKELETAL RESTRICTIONS YES _____ NO TUBES / DRAINS / CATHETERS _____ (include size and location) N/A DRESSINGS / CAST / SPLINT YES _____ NO COUNT CORRECT YES NO >>> XRAY TAKEN OTHER (labs, path results, etc) _____ Patient TRANFERRED TO PACU CVICU REPORT GIVEN TO _____ RN >>>> REPORT GIVEN BY _____ RN (relief only) REPORT GIVEN TO _____ RN >>>> REPORT GIVEN BY _____ RN (relief only) REPORT GIVEN TO _____ RN >>>> REPORT GIVEN BY _____ RN ** NOT PART OF Patient CHART** Patient name and MR # Courtesy of Kaiser San Francisco.

7 Used with permissHandoff CommunicationsSentara Norfolk General Hospital, Norfolk, Virginia 23507 SNGH PACU REPORT WORKSHEET Form must be filled out completely Patient Date:_____ Room assigned:_____ (Place sticker here) Surgeon:_____PRECAUTION Type Bed: Regular / Telemetry Class I II / Step down / SD Telemetry / ICU Allergies: _____ Reaction: _____ Isolation Yes No Type_____ Oxygen NC_____ FM _____ VENT_____ Type of Surgery_____Type of Anesthesia: General / Sedation / Local / Spinal / Epidural / Block Medications given PACU: Versed____ Fentanyl _____ Dilaudid _____Morphine____ Time Last narcotic given_____ Other_____ Anitemetic_____ Antibiotic_____ Time next dose due _____ PCA Medication_____Settings_____Time Started_____ Medical History _____ _____PLAN OF CARE Fluids in.

8 OR_____ PACU_____ IV fluid /Rate_____ IV access &location_____ Output OR_____ PACU_____ Foley present Y / N EBL OR_____ PACU_____ DRAINS OR_____ PACU_____ Number of and location of drains:_____ DRESSINGS_____ PROBLEMS : Vital Signs: Time: T_____HR_____ RR_____B/P _____Pulse Ox _____Pain Scale____ Review systems (WNL otherwise noted) Neuro/Vascular :_____ Respiratory: _____ Cardiac/Rhythm: _____ GI / Diet (has Patient started ice chips)_____ GU: _____ Musculoskeleton: _____ Kendalls Y / N Labs _____ Xrays_____ Blood Sugar_____ PURPOSE Time Bed Ready_____ Time Report Faxed _____ Nurse Completing Report_____ Time Patient arrived to floor_____ On floor bed Y / N Courtesy of Sentara Norfolk General Hospital.

9 Used with CommunicationsCourtesy of WakeMed Healthcare Health and Hospitals. Used with permission. Handoff CommunicationsSBAR Patient Report Guidelines: Perioperative Services Report given by: Time: _____ Phone: _____ Report received by: Phone: _____SSituation: Patient s name, Age, gender NPO status (# of hours) Allergies S Diagnosis/Procedure being performed Advanced Directive, Code status BBackground: History / Past hospitalization Infection Control/Isolation Primary Language Special needs spiritual, cultural, learning, communication Religious needs-refuses blood transfusion B Legal status Disposition of Patient belongings AAAssessment.

10 Current Status - Preop to ORCurrent Status - OR RN to OR RN Planned surgical procedure Current stage of procedure Surgical procedure verified and marked Anesthesia type Planned anesthesia type Allergies Mental status Position of Patient /devices used Allergies Significant medical history Language barriers Blood products/Consent Blood products/Consent Recent changes in condition Medications received in preop Medications on the sterile field Antibiotics to be given Irrigation fluids in use Blood products available Instrumentation on/off field - needed Significant medical history (Elevated BP, cardiac, asthma, etc.) Equipment/device needs Implants needed available Equipment needs (SCD, etc.)