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Cultivating Quality: Implementing Standardized Reporting and Safety Checklists

Stevens, James D. MSN, RN, CNS; Bader, Mary Kay MSN, RN, CCNS, FAHA; Luna, Michele A. PhD, RN, CPHQ; Johnson, Linda M. MSN, NEA-BC

AJN The American Journal of Nursing: May 2011 - Volume 111 - Issue 5 - p 48-53
doi: 10.1097/01.NAJ.0000398051.07923.69
Feature Articles

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

This study examines one hospital's efforts to build a culture of safety by implementing standardized nurse-to-nurse reporting and safety checklists.

James D. Stevens is a clinical instructor at Long Beach Memorial Medical Center in Long Beach, CA. Mary Kay Bader is a neurology/neurosurgery and critical care clinical nurse specialist at Mission Hospital in Mission Viejo, CA, where Michele A. Luna is a quality manager and Linda M. Johnson is a vice president for patient care and the chief nursing officer. Contact author: James D. Stevens,

© 2011 Lippincott Williams & Wilkins, Inc.