Media Release

June 2, 2009

ATTN: NEWS / HEALTH EDITORS

Trillium Health Centre’s Transfer of Accountability ‘Safe Patient Hand Off’ receives CCHSE Health Care Safety Award

Trillium Health Centre’s Safe Patient Hand Off - Transfer of Accountability initiative was awarded the Canadian College of Health Service Executives “Health Care Safety Award” on Sunday, May 31, 2009 at an awards ceremony in St. John’s, Newfoundland

“Our project was inspired by all of the outstanding nurses at our Mississauga and West Toronto locations and by their commitment to patient safety,” said Susan Bisaillon, Director, Neuroscience/MSK Health System and Complex Continuing Care at Trillium Health Centre. “In the hospital setting, the care of a patient is typically transferred from one nurse to another during a shift change. Yet, studies show that patients are most vulnerable to sentinel events from miscommunication at hand-off.”

Transfer of Accountability (TOA) or Transfer of Care (TOC) can be described as a “system of nurse-to-nurse communication between shift changes intended to transfer essential information for safe, holistic care of patients.”

The format of TOA varies widely across the country. Verbal report is the most popular format. During this process, critical information about patients such as vital signs, clinical condition, abnormal findings, pending diagnostics and treatments, and the plan of care are communicated between the outgoing and oncoming nurses. When patient care is transferred from one nurse to another ineffectively or incompletely, patient safety can be jeopardized.

Within Trillium, Orthopaedics and Cardiac Surgery served as the pilot units in which a new process was implemented, evaluated and improved. The Orthopaedic Surgery unit developed a comprehensive standardized template (posted at each patient bedside) for the nurses to use when giving verbal report. This standardized template serves as a trigger for communication so that vital information is not forgotten and includes “five checks at the bedside” including: alarms; armbands; allergies; patent intravenous; and an environment check to identify any potential patient safety risk factors.

The Cardiac Surgery pilot also incorporated a new standardized framework for nurses to use during the reporting process, based on the acronym SAFE (S= Story, A= Assessment, F= Follow-up, E= Evaluation).

“The goal of Trillium's Transfer of Accountability - Safe Patient Hand Off initiative was to provide a structured, interactive, collaborative communication between staff and their patients to involve the patients by sharing timely, accurate information about their care plan, treatment, current condition and any recent or anticipated changes,” said Cecile Marville-Williams, Manager ,Cardiac Services Patient Unit at Trillium. “By improving the transfer of accountability process we have seen marked improvements in efficiencies and effectiveness as well as enhanced quality of patient care and increased patient and staff satisfaction.”

Feedback from Orthopaedic Unit nurses to the new TOA process is very positive. Nurses report identifying near misses at change of shift, having the opportunity to ask questions, receiving additional information from patients, and checking all aspects of each patient’s condition - with the previous nurse present - as significant impacts of the new process. Similarly, Orthopaedic patients appreciate report at the bedside, because they know what’s going on and who their nurse is at all times, and are reassured that the nurse coming on shift knows everything about their care.   

Trillium Health Centre's team built on the work of other hospitals, including Hamilton Health Sciences, to provide a new benchmark for providing a consistent, comprehensive and complete interactive reporting process that promotes collaboration with the patient and family.  The results have been so positive that Trillium is committed to the expanding this new Safe Patient Hand Off process across the health centre. 

About Trillium Health Centre
Trillium Health Centre is one of Canada’s largest academically-affiliated tertiary care hospitals with highly-specialized regional programs in advanced cardiac, vascular, stroke, neurosciences, orthopaedic, and sexual assault/domestic violence services. Housing a model ambulatory care centre and the largest free standing day surgery centre in North America, Trillium serves over one million residents in Peel and West Toronto and from other communities across Ontario. Last year Trillium’s doctors, staff and volunteers cared for more than 700,000 patients at the Mississauga (100 Queensway W.) and West Toronto (150 Sherway Dr.) locations. With the continued support of the Trillium Health Centre Foundation, the hospital’s fundraising arm, the two-site facility is attracting international attention for its innovative approach to providing safe, high quality health care services and has received numerous national awards for quality and innovation.

For more information, go to www.trilliumhealthcentre.org.

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Media Contact:

Larry Roberts
Media Relations Consultant
Trillium Health Centre
Office: 905-848-7580 ext. 3832
Mobile: 416-358-7201
lroberts@thc.on.ca

Media Contacts

For all media enquiries, please call Public Relations at 905-848-7580 ext. 3832.