SHM Converge Scientific Abstract ePoster Gallery-Using Quality Improvement Methods to Enhance Nurse-Physician Communication

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This quality improvement project aimed to reduce misdirected pages from bedside nurses to the wrong medicine team at the VA Tennessee Valley Healthcare System. Poor nurse-physician communication can delay care and cause information loss, and residents were frequently receiving pages for patients they were not managing.<br /><br />The team identified root causes using a fishbone diagram. The existing system relied on admission orders to identify the “first contact” intern for each patient, but some admit orders did not clearly include pager information, and older orders created opportunities for error. The project goal was to reduce unnecessary pages to the incorrect team to 3 per week within 3 months of implementing new admission orders.<br /><br />Three interventions were planned:<br />1. Educate nurses on how to identify the first contact.<br />2. Standardize admission orders so they are clearly visible, intuitively labeled, and editable.<br />3. Standardize admit order entry so orders are automatically deleted at discharge.<br /><br />Component 1 was implemented in September 2023. However, from August 2023 through March 2024, misdirected pages ranged from 4 to 28 per week, with an average of 12 per week. The rate remained relatively stable despite the nurse education intervention.<br /><br />The conclusion was that using admission orders to identify the first contact created an unintended workflow problem that education alone did not fix. The authors concluded that system-level changes, rather than education alone, are needed to reduce misdirected pages. The next steps are to implement the standardized admission order improvements and auto-deletion process.

Asset Subtitle

Maureen K. Fausone

Meta Tag

Author List Kelly Sopko, Maureen K. Fausone, Michael J. Ward, Terra Swanson

Category Innovations

Concept Nurse-Physician Collaboration

Concept Misdirected Pages

Concept Delay in Care

Concept Root Cause Analysis

Concept Admission Orders

Distinguished Non-Finalist

Presenter Organization Tennessee Valley Health System, Nashville VA Hospital

Presenting Author Maureen K. Fausone

Track Quality Improvement

Keywords

quality improvement

misdirected pages

bedside nurses

medicine team

VA Tennessee Valley Healthcare System

nurse-physician communication

admission orders

first contact intern

fishbone diagram

system-level changes

Nurse-Physician Collaboration

Misdirected Pages

Delay in Care

Root Cause Analysis

Admission Orders