National Patient Safety Goal #2: Improve the Effectiveness of Communication Among Caregivers


"One important component of this goal is to ensure timely reporting of critical tests and critical test results so care to patients is not delayed. Organizations may find it challenging to measure and assess the effectiveness of their efforts around timely reporting and retrieve the data to demonstrate that monitoring occurred and that the intervals were acceptable. My advice is to define acceptable intervals and set up a system where the data is easy to retrieve."

"As for abbreviations, I have seen attempts by organizations to implement 'workarounds‘ to the unapproved abbreviations list. For example, MgSO4 is on The Joint Commission's unapproved abbreviations list. However, organizations have substituted MagSO4 as being 'acceptable'."

While it is true MagSO4 is not specifically mentioned in the NPSG, it could still be misinterpreted and there is a high potential for errors. Abbreviations have been identified as the root cause in medication sentinel events."

Hand-off communication is another major component of this goal. There are numerous types of hand offs, including but not limited to nursing shift change, physicians transferring responsibility of care to another physician, temporary responsibility for staff leaving the unit, and reports between departments, such as surgery to post-anesthesia care and back to the nursing unit. In order for hand-off communication to be effective, up-to-date information regarding the patient's condition, care, treatment, medications, services and any recent or anticipated changes in the patient's condition must be communicated.

Again, JC expert, "organizations that have been successful in meeting this goal have implemented checklists that serve as prompts to ensure all elements of the patient care are covered during the hand-off communication. During the hand-off process, the receiver of the information should be given the opportunity to repeat or read back information for confirmation, and given the opportunity to ask clarifying questions. Since the 2009 goal requires increased documentation, the use of checkboxes or lists may work well. Examine each and every existing form that might be used in gathering 'handoff' information and determine if adding a documentation checkbox can facilitate the documentation requirement without adding another form."

In summary, NSPG # 2 is about reducing risk and improving safety by standardizing communication whenever possible. National Patient Safety Goals are not prescriptive in stating "how" organizations should achieve compliance, thus allowing organizations to be creative in their approach to achieving the intent of the specific goal.

Be sure to include members of the care delivery team from all disciplines when designing systems and processes around improving communication. Participation of front line staff will help ensure sound processes are developed and will become your champions for achieving success.