Article | January 25, 2018

4 Steps To Address The Joint Commission's Sentinel Event Alert On Hand-Off Communication

Source: Vocera Communications

By Rhonda Collins, Vocera

4 Steps Join Commission Hand Off

“I’m bringing a patient up,” says Mark Frye, a nurse in the PACU. “Ted Jones, 33 years old. He came in through the ED. We believe he was in a motor vehicle collision. He has an open compound fracture of the left femur with external repair. He remains unresponsive with a head injury of unknown cause.

“Alright, I’ll meet you in the room,” responds Mary Smith, the patient-receiving nurse in the ICU.

Transport brings the patient up to the ICU. Nurse Frye tells Nurse Smith what he knows, based on information from the surgical team, which was based on information from the trauma team.

Nurse Frye turns to leave, and pauses. “Oh – by the way, I got an order for different pain meds but I’m not sure if it’s in the EHR,” he says.

Nurse Smith nods and thanks Nurse Frye as he walks away. She looks at Ted Jones, this unconscious man with no voice. She wonders: What is his story?

She doesn’t have much time to wonder, because she has to get to work re-assessing the patient and placing him on ICU protocols. She changes out his IV tubing. She transitions him to the room ventilator and assesses his bandages to see if there’s any drainage. The cardiac monitor in ICU is not the same type used in the PACU, so she changes out EKG leads. She is doing research from head to toe and documenting all of it. It might be hours before she can go look at the EHR and see that orders have changed.