166 - Development of Peri-procedural Hand-off Tool Utilizing the Electronic Medical Record
Description: The team consists of members of Clinical Practice Committees and a multidisciplinary group of perioperative nurses collaborating with representatives from Information Technology and the Quality and Safety departments. Preparation and planning After a collaborative case review of a high-risk sentinel event in the periprocedural area, a breakdown in hand-off communication was discovered. This communication breakdown prompted a collaborative discussion to improve a hand-off report ensuring standardization of hand-off report leveraging the capabilities of the electronic medical record. Assessment A review of current practice and literature was performed and evaluated. The capabilities of the electronic medical record were assessed and incorporated into workflow. Discussions were initiated at nursing Clinical Practice Committees, and Periprocedural Safety committees to develop a mechanism of hand-off designed to minimize opportunities for communication breakdown. Implementation In the initial stages, paper hand-off tools were used with the intent to determine pertinent information should be included in the electronic hand-off tool. The electronic hand-off tool was designed to bring in information already present in other locations within the electronic medical record into one central location. Though the electronic medical record contains all the information needed for an effective hand-off, accessing that information was cumbersome and time-consuming. Outcome Teams continue to meet to discuss optimum hand-off tool components. Barring feedback and evaluation, at the next electronic medical record update will incorporate the necessary build requests. The team has a standardized communication process for transition between nursing teams. The communication process does not add extra work flow due to the electronic record populating the hand-off tool automatically. Implications for perioperative nursing The literature indicates that communication breakdown due to either omitted or incomplete information at hand-off is a leading cause of sentinel events CITATION The171 \l 1033 (The Joint Commision , 2017). With the use of a hospital wide electronic health record, information should be readily available. However, there was a lack of standardization and application in the perioperative environment. Hand-off tools such as IPASS are utilized in the perioperative setting at our facility, but the information is either on paper or verbalized due to the lack of a centralized location in the electronic record. AORN and the Joint Commission echo the growing body of research supporting the need for effective communication, especially at hand-off. An interdisciplinary team is working to create an electronic hand-off tool that integrates the information from the electronic medical record and consolidates the information to one location, so it can be utilized during any care transition.