Developing processes to create a culture of safety.
Background: It's estimated that as many as 98,000 hospitalized patients lose their lives each year in the United States because of medical errors that could have been prevented. While standardized reporting and safety checklists have been shown to improve communication and patient safety, implementation of these tools in hospitals remains challenging.
Objective: To implement standardized nurse-to-nurse reporting along with safety checklists at Mission Hospital, a 522-bed facility in Mission Viejo, California, using Lewin's change theory and Knowles's adult learning theory.
Methods: Nurses were tested to assess their knowledge of the standardized nurse-to-physician reporting method called SBAR (Situation, Background, Assessment, Recommendation), their understanding of the concept of the nurse-to-nurse reporting method called SBAP (Situation, Background, Assessment, Plan), and the use of safety checklists. Then, after viewing a 22-minute educational video, they were retested.
Results: A total of 482 nurses completed the pretest and posttest. On the pretest, the nurses' mean score was 15.935 points (SD, 3.529) out of 20. On the posttest, the mean score was 18.94 (SD, 1.53) out of 20. A Wilcoxon matched-pairs signed-rank test was performed; the two-tailed P value was < 0.001.
Conclusion: The application of Lewin's change theory and Knowles's adult learning theory was successful in the process of implementing standardized nurse-to-nurse reporting and safety checklists at Mission Hospital.
Keywords: medical errors, nurse-to-nurse reporting, nursing handoffs, safety checklists, SBAR, standardized report