Aim of Project Improve patient safety and reduce the incidence of critical incidences or near misses through effective communication when initial assessment undertaken in the Maternity Assessment Unit.

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Primary Drivers • Improve patient safety and reduce the incidence of critical

incidences and near misses through the use of an effective communication tool at every contact with the Maternity Assessment Unit.

• Raise awareness of local critical incidents/near misses through poor communication.

• Clearly identify patients on the red or green pathway. orep eliquidust

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Secondary Drivers • Conduct an online search for examples of SBAR

(Situation, Background, Assessment, Recommendation) • Advertise and promote SBAR more vigorously linking in

with the Obstetric Speciality Management Team, Labour and Birth Forum, Critical Incident Review Group and documentation study days to raise awareness with all staff groups.

• Engage with and ensure cooperation with all staff groups in the provision of care.

• Introduce a buzz word/phrase which will allow staff to question without alarming the patient.

• Encourage staff to clearly identify patients on the green or red pathways.

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Project Actions/Processes

• Gathered local information from the Head of Midwifery and staff who process and action any Datix or complaints which are received.

• Gathered information about the use of SBAR and how it can be used to improve patient safety.

• Asked members of staff who had an interest in looking at SBAR and who were keen advocates for the introduction of SBAR at patient handover for help to implement same

• Did an online search for examples of SBAR to see if any could be adapted for maternity services.

• Using the PDSA process the SBAR assessment tool for the Maternity Assessment Unit was formed.

• A staff competition was run to come up with a buzz word or phrase to allow staff to question without alarming the patient and to do so in a professional manner.

Results/Evaluation Local information was not easily accessible, however it became apparent that in a 13 month period 17 clinical risk Datix reports had been received which could solely be associated with poor communication within the maternity service. It was quite easy to find staff who were interested at looking at the introduction of an SBAR system – it was not easy to find the time to meet up. The Maternity Assessment Unit seemed the obvious place to start because women who were seen there had a concern or problem with which was either a deviation from the norm or they were in the early stages of labour. Therefore good communication and handover was critical. An SBAR tool was drawn up. 1 member of staff was asked to trial it and it was then audited. This process was carried out 6 times with different members of staff. Each time changes to the form were made as appropriate dependant on the feedback until the final SBAR document was agreed. The feedback is now very positive from all members of the team involved in the audit. A competition is in the process of being run to come up with a buzz word or phrase which can be used to allow staff to question without alarming the patient. All members of the multidisciplinary team who work in or alongside maternity services were eligible to participate. It was advertised and discussed and all members of the multidisciplinary team are keen to engage with the idea. During February and March 2013 the buzz word or phrase will be rolled out and the SBAR tool for the Maternity Assessment Unit will be implemented for all patients who come into contact with maternity services through this route. This will involve training to all staff involved. SBAR leaflets will be handed out at this time to all staff. It is hoped that this will lead to better communication within the team and a reduction in incidents associated with poor communication. It is also hoped that the use of SBAR can be adapted for use at other points of patient contact within the maternity services.

Raising awareness of the effects of Poor communication and implementing use of SBAR at handover in Dumfries and Galloway Project Leader: Gillian Jess

SBAR  Situation,  Background,  Assessment,  Recommendation                                                                                                                                                                                                                                              Maternity  Assessment  Unit.                                                                                                                                                                                                                                                                                                                                                                                                                                              

S      B      A          R    

Date                                                                                  Time                                        CHI  No    Patients  Name:                                                                                                                                                      Reason  for  call  &  concern                                                                  

Parity:      Gestation:                                                                                  Any  problems/concerns  this  pregnancy?      

Relevant  medical/Obstetric  History      Medication    

Obs      HR                          BP                          TEMP                                                          RR                                              SA02                                                                              FH/CTG                              FMF                    Urinalysis    Blood  group                                                      PV  loss    Palpation      

The  problem  is    

 

Signature:                                                                          Print  name:                                              Designation:                

   

Effective  communication  will  reduce  the  risk  of  critical  incidents    -­‐    Use    and  learn                              S  B  A  R