Transition from Unidirectional to Bidirectional
Text Paging System with Use of Voalte System
The Voalte system has been in place as a text
paging system since it was purchased by Hill-
Rom in 2018. It’s highly affective and reliable for
communication. It offers real-time tracking,
phone calls, and text messages all within
compliance of HIPAA.
Why is this an issue?
– Unidirectional paging systems lack standardization and
do not indicate level of urgency. Communication
errors are the most common cause of preventable errors
related to critical labs, patients, and how long it takes for
providers to assess the patients in a timely manner.
– The Joint Commission currently identifies
communication failure as one of the most common causes
of sentinel events.
Transition to secure text messaging
system as a bidirectional method of
communication within the acute care
setting, in comparison to unidirectional
traditional paging systems to improve
nursing and staff satisfaction and patient
outcomes, resulting in a decrease in
patient delay of care.
In review of over 14,000 hospital admissions,
communication problems were found to be the
most common cause of preventable errors.
It is not routine to address the paging
systems on an annual basis. Little to no
feedback is acquired from
administrative personnel. The goal of
this intervention is to improve
satisfaction with caregivers on all levels
with a specific mean of communication
AND to improve patient care and
Approach to risk
In a breakdown of malpractice issues in the
Emergency Department, 12% of cases were due
to communication errors and 9% were related to
delay of care.
P: Survey – Ideas regarding what current changes caregivers in
the acute care setting would like to see regarding change.
What is the current favored method of communication? Have
they experienced any sentinel events d/t lack of
D: Test the theory for areas of improvement (Cycle 2). Educate
staff members about opportunities for improvement.
S: Direct observation of nursing staff within ICU.
A: Follow one nurse, one provider, and one patient during shift.
Observe and take notice of communication methods and time
it takes for response.
P: Does a bidirectional secure messaging system help to
prevent and reduce the number of communication errors?
Discuss with 3 RNs, 2 MDs, 1 RT, 1 PCA
D: 3/3 RNs, 1/2 MDs, 1/1 RT, and 1/1 PCA were open to the
idea. There was hesitancy related to resistance to change.
S: Informational documents to include purpose, statistics, and
pictures were helpful to staff members.
A: Open the discussion to more staff members within the ICU.
Gather baseline data from
nurses, techs, providers, midlevel
providers, therapists regarding
current satisfaction in paging
documents to ICU stOriginal work, cite, reference, no plagiarism
I provided an example of how it should look
Phase 3 will focus on your communication about your PDSA project. To begin this, review and download the application PiktoChart from your App Store, the initial subscription is free for 30 days. Review the site and begin considering how you will visually display your processes, population and findings from the 3-cycles of your project.
You will use PiktoChart to create an Inforgraphic that shares your PDSA findings.
To achieve a successful grade in this assignment you should find a means of displaying within the infographic the following:
· Visual representation of the PDSA Model
· PICOT question is stated
· Evidence- based documentation summary/synthesis is provided
· What h
appened and what
was changed in your 3-cycles of review
· What was the quantitative/qualitative data (no matter how small)
· Show a summary/graphic of your findings
· Benchmark comparisons for your performance measures
· Provide recommendations
· Discuss next steps
· Infographic is clear, educational, evidence driven
· Include appropriate citations using APA Style format.
Apply creativity to communicate visually your PDSA findings.
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