Professional Documents
Culture Documents
Safety
Oleh :
Wawan wahyudi
Disampaikan Pada Penyegaran Bagi Perawat RS M Djamil Padang
Padang, 6 November 2014
For verbal or telephone orders
For reporting critical results
Method:
The individual receiving the information
Writes down the complete order or test result, or
Enters it into the computer
The individual receiving the information
Reads back what has been written
The individual who gave the order
Verifies the correctness
Check-back is a good way to verify information
especially when transcribing a doctors order.
Medical orders must be reviewed for
completeness and clarity.
The medical orders must be questioned if
penmanship is illegible or abbreviations are
used that are not acceptable by the
institution.
Call-out is another technique when a critical
information is called out during an
emergency situation.
The critical information is said aloud so that
any team members present during an
emergency that are hearing and listening to
the information.
Hand-off is another technique of verbally transferring
information, responsibility, and accountability of patient care to
another staff.
This includes the review of written report on the pertinent
patient information, the latest significant changes in patient
status, and the latest recommendation on the plan of care.
The receiving staff has to acknowledge the completeness,
pertinence of information, and accepts the responsibilities in
providing patient care.
Using the S-B-A-R method in hand-off will enhance
communication and promote a culture of patient safety.
S-B-A-R is an abbreviation for : Situation,
Background, Assessment and
Recommendation.
Giving information systematically and
consistently
SBAR should be used when giving patient
information between primary caregivers
regardless of discipline.
SBAR is a technique that provides a
framework.
easy-to-remember
allows for an easy and focused way to set
expectations
Communication Tools : SBAR
Situation: What is going on with the patient?
What is happening at the present time?
Background: What are the circumstances leading
up to this situation?What is the clinical
background?
Assessment: What is the problem? What is the
current situation?
Recommendation: What should be done to
correct the problem?
------- Response/Repeat back: Repeat back the plan
of care
PENDAHULUAN
Clinical Handover in Nursing ; is defined as
the transfer of responsibility and
accountability for patient care from one
provider or team to another (Australian
Medical Assosiation,2006)
Key Initiative to improve patient safety
(Australian Commission for patient safety and
Quality in Health Care, 2007 and WHO, 2007)
Dimensi Clinical Handover
Responsibilitas
Accountabilitas
Patient safety
PendekatanPatient Center Care
Kepuasan pasien dan perawat
Continuity of Care
Tekhnik Clinical Handover
Sangat bervariasi :
1. Verbal handover
2. Tape recorded handover
3. Bedside nursing handoverface to face
4. Written handover
(Miller,1998. Sexton et all 2004)
SKEMA PROSES BEDSIDE HANDOVER
(Australian Commission for patient safety and Quality in Health Care, 2007 )
3.
2. 4.
1. Information 5.
Introduction Patient Next Patient
Preparation Exchange : Safety Scan
Involvement
SBAR
DESKRIPSI BEDSIDE HANDOVER
Pertimbangan Perawat :
1. Kenyamanan Pasien saat proses handover
2. Keterlibatan dan fokus keluarga thdp kondisi pasien
3. kerahasiaan
Update lembar overan/handover sheet
Data
Demografi Discharge
Perubahan
Medikal Planning
Kondisi
history Sensitif
Test dan hasil
Sosial history informasi
Perawat yang
akan masuk
memberi salam
2. pada pasien
Introduction Perawat yang
akan keluar
memperkenalkan
perawat yang
akan masuk
Partisipan :
1. Outgoing team leader/Katim
2. Incoming staff/ perawat yang akan masuk
3. Patient and family
4. Shift co-coordinator /Karu
DESKRIPSI BEDSIDE HANDOVER
Kondisi Klinis
Test dan prosedur
3. Bantuan Activity daily
Information living
Discharge Planning
Exchange Queries from oncoming
staf
SBAR
Sharing Informasi :
1. Perubahan kondisi pasien
2. Perubahan
Sharing Informasi umum selama bedside handover berlangsung
(Examp.1)
SBAR ISOBAR
R: Risk Management
DESKRIPSI BEDSIDE HANDOVER
Tanyakan apakah
pasien ingin
bertanya atau
berkomentar
4.
Beri kesempatan
Patient pasien
mengkonfirmasi
involvement dan m-klarifikasi
informasi
Kerahasiaan :
1. Informasi yang sensitif disampaikan pada kondisi privat
2. Informasi yang sensitif dapat dicatat laporan/handover sheet
Aspek penting dalam pendekatan konsep
patient center care
Memberi kesempatan pasien m-konfirmasi
dan m-klarifikasi informasi tentang dirinya
Outgoing nurse memotivasi keterlibatan
pasien dan klgnya selama overan
Penurunan partisipasi; pasien dg penurunan
kesadaran,isolasi,kesulitan berkomunikasi
Confidentiality/Kerahasiaan
pastikan semua
5. peralatan
berfungsi
Akses untuk alat
Safety mobilisasi
Cek Tube and line
Perhatian Perawat :
Final Quastion
NEXT PATIENT
5. Safety Scan