Risk Profile: Care – Communication/coordination

Risk Profile: Care – Communication/coordination (PDF version)

Inappropriate care communication and coordination issues – including, but not restricted to, inadequacies in communication, hand-offs, discharges, consultation, coordination and case management – can lead to dissatisfied patients and families and patient safety issues. This document contains information entered by your peers in the Risk Register application to help you manage this risk.

Ranking/ratings[1]

  • Likelihood – average score 3.46
  • Impact – average score 3.27

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/Mitigation strategies

  • Clinics
    • Referral criteria, refreshed, and updated annually
    • Clear guidelines for referral triage
    • Appointments booked depending on urgency of care and appointment details communicated timely to patient
    • If there is no clinic appointment available within triaged timeframe contact referral source to review potential options within the most responsible physician (MRP) clinic or new referral reassigned to another MRP to be booked within agreed upon timeframe
    • Reducing overall surgical wait times is a key objective
  • Emergency Department
    • Standardized triage criteria
    • Physical space designed to maximize visibility and patient flow
    • Standardized care pathways and medical order sets/directives for common conditions
    • Staffing resource plan for surge in volume
    • Reassessment process for patients waiting to be seen to monitor status change
    • Standardized follow-up process for patients who leave ED without being seen by a physician
    • Awareness campaign to emphasize importance of accurate demographic information at patient registration
    • Surge plan for patient flow
    • Clinical indicators at triage regarding infection control (i.e. MRSA, VRE, C-diff)
  • Diagnostic Imaging
    • Awareness campaign regarding importance of accurate patient information on requisitions
    • Process to inform MRP for requisitions requiring redo; missing clinical information
    • Request for legible requisitions and/or further clinical information (radiologist to physician)
    • Electronic Medical Records (EMR) print requisition with direct link to patient demographics and electronically ordered tests
  • Medication
    • High-risk medication(s) protocol/policy
    • ICU/floor medication reconciliation at admission and discharge and transfer
    • Electronic allergy management system (admitted patients)
    • Role clarity regarding the collection of allergy information (nursing/pharmacy/dietary)
    • Only clinical staff enters allergies into the EMR
    • Coloured armbands for allergies
    • Staff training and mandatory refresher e-learning for allergy identification
    • Procedures for inquiring about allergies before giving medications
    • Individual feedback when errors are made. Patient disclosure process if error reaches patient
    • Use of pharmacist on multidisciplinary rounds to lower adverse drug events caused by prescribing errors
    • Assistance with development of protocols or guidelines by pharmacists for safe and appropriate sedation
    • Use of sedation guidelines and pharmacist interventions to reduce the overall use/cost of sedative drugs
    • Goal-directed sedation with clear sedation targets to reduce the duration of intubation/total ICU length of stay
    • Staff education on sedation scale
    • Education for patients and families regarding the side effects of medication and communication protocol to let staff know if experiencing a side effect
  • Obstetrics
    • Escalation of fetal status protocol/policy
    • Regular staff education/simulations/fetal surveillance
    • Daily multidisciplinary huddles
    • Quality/risk huddles if infant cord gas <7
    • Education rounds with case study/review
    • MOREOB (Managing Obstetrical Risk Effectively program)
    • Standardized response (algorithm) to atypical fetal heart rate
    • Monitoring equipment ‘flags’ nurses’ station
  • Laboratory/critical test results (CTR)
    • CTR protocol/policy
    • CTR flags in EMR
    • Physician accountability for daily review of lab/late results
    • Standardized process for follow-up of results reported after patient discharge, to discharging and primary care physicians
    • Communication of CTRs recorded in lab IT internal systems
    • Documentation to show attempts made to share results
    • Decision trees constructed in lab for whom to phone if MRP cannot be reached
    • In acute care call the unit and then if patient already discharged protocol in place to contact the MRP
    • Patients contacted about CTRs requesting they return to ED. Document.
    • ED physician accountable to review late arriving lab results daily
    • ED Nurse Practitioners/Physician Assistants participate in family call-backs on late-arriving lab results
    • Escalation strategies to support timely notification of late-arriving lab results
    • Standardized process in place to follow-up on positive microbiology culture results post ED discharge
    • Occurrence reporting for lack of compliance
    • Daily logs of pending results for tests and critical results printed daily (organizations with EMRs)
    • Standardized handover utilized (includes test review as part of patient summary)
  • Discharge/transitions
    • Comprehensive interdisciplinary discharge process/checklist
    • Process for early identification of patients at high risk
    • Critical information transmitted to family physician and/or home care providers
    • Patients/families included in discharge planning process and identification of homecare needs
    • Plain language discharge instructions for patients/caregiver or substitute decision makers
    • Utilizing Accreditation Canada’s Required Organizational Practices (ROP) guidelines to implement new tools, procedures and improve practice
    • Discharge/aftercare planning protocols
    • Annual client safety training required by staff and volunteers
    • High-level education on client safety for new hires
    • Clinical pathways for discharge
    • Fully comply with mitigation strategies of HIROC Risk Assessment Checklists program discharge module
    • Transfer of accountability at patient discharge to appropriate health care provider(s)
    • ED chart faxed to family physician following ED visit and/or MRP receives notification of patient’s ED visit via electronic health record
    • Nurse Practitioner/Bed Manager/Unit Manager attends bed rounds for continuity of patient information
    • Nurse Practitioner/Bed Manager/Unit Manager facilitates earlier discharges from hospital to long-term care facilities to decrease length of stay/enhance continuity of care and communication between acute care and long-term care sector
    • Nurse Practitioner supporting teams averting transfers from long-term care facilities to EDs (avoiding hospital visits and admissions)
    • Interdisciplinary rounds in the ED and on nursing unit. Daily bullet rounds in acute care and multiple times a week in post-acute care
    • Discharge support meeting held with families, homecare
    • Improved electronic communication with physicians
    • Supporting teams averting transfers from long-term care facilities to EDs (avoiding hospital visits and admissions)
    • Instill the Teach-Back Method so patients can demonstrate they have an understanding of their care expectations
    • Discharge follow-up phone call program
  • Patient/family-centred care
    • Family forum
    • Patient/family engagement on committees and/or review of specific initiatives
  • EMR/hybrid chart/documentation
    • Clinical panels to assist clinicians to identify key clinical information (between EMR and paper record)
    • Staff education
    • Structured interprofessional meetings/rounds
    • Standardization of physician documentation regarding plan of care
    • Documentation policies
    • Documentation staff training

Monitoring/indicators

  • Occurrence reports related to communication and coordination
  • Quality reviews related to communication
  • Audits of key communication processes (e.g. medication administration, CTR)
  • Patient satisfaction surveys; patient/family complaints related to communication/access
  • Clinic referral data/volumes/efficiencies
  • ED patient flow and wait time indicators
  • Monitoring physician discharge summary compliance
  • Number of adverse drug events from receiving a medication patient was allergic to
  • Number of near misses reported
  • Corporate Scorecard indicator to drive wait times and improve access to clinics
  • Standard Referral Management audit system in place for every clinic
  • Audit of occurrence reports/Neonatal occurrences with harm
  • Quality review to monitor and review compliance with the CTR policy
  • Occurrence reports completed when significant test results are not followed up
  • Morbidity and mortality review related to communication and coordination
  • Ongoing issues identified and monitored through staff and physician feedback
  • EMR staff and physician group meetings to discuss issues and recommend strategies (short and long-term)

[1] As of January 1, 2017

Note: information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.

© 2017 HIROC. For quality assurance purposes.